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^URGEON-LIEUTENANT,       ROYAL      NAVY    ;      SURGEON,      ROYAL       AIR       FORCE 






MARTIN    FLACK,   M.A.,   M.B. 





OLIVER    H.    GOTCH,    M.B.,   Ch.B.,   M.R.C.P.    (London) 



















I  AM  conscious  of  the  fact  that  this  is  the  first 
book  of  its  kind,  and  forgiveness  is  asked  for  its 
many  shortcomings.  It  is  rare  in  modern  times  to 
be  given  the  opportunity  to  find  a  new  subject 
upon  which  to  write.  Aviation,  within  the  last  few 
years,  has  undergone  such  enormous  developments 
in  the  design  and  construction  of  machines,  making 
for  increased  power,  stability,  speed  and  climb, 
that  one  might  be  tempted  to  think  that  the  human 
machine — the  aviator — had  been  somewhat  over- 
looked. This  has  not  been  the  case  ;  on  the  con- 
trary, to  some  of  us  in  our  profession  the  choice  and 
care  of  the  aviator  have  proved  a  new  but  interesting 
subject  for  investigation,  and  at  the  same  time  an 
absorbing  study. 

The  vagaries  of  the  Great  War  have  thrown  many 
of  us  out  of  our  "  lonely  furrow  "  to  plough  afresh 
a  new  soil,  perhaps  along  totally  different  lines.  The 
ophthalmologist  may  have  found  himself  a  battalion 
doctor,  the  throat  and  nose  specialist  in  charge  of  a 
field  ambulance,  and  the  gynaecologist  perchance  a 
naval  surgeon.  In  my  own  case  it  meant  laying  down 
consulting  surgical  work  for  the  life  of  an  aerodrome 
medical  officer. 

On  joining  the  Royal  Navy  at  the  outbreak  of  war 
I  was  attached  to  the  Royal  Naval  Air  Service  ; 
and,  since  then,  for  tlie  past  four  years  I  have  lived 
with  aviators,  flown  with  them,  and  entered  for  the 
most  part  into  their  interests,  studying  them  alike 
in  war  squadrons,  in  aeroplane,  seaplane,  and  airship 
stations,  and  in  hospitals  specially  devoted  to  their 


maladies.  I  have  also  been  associated  with  aviators 
of  our  late  Royal  Flying  Corps,  with  those  of  the 
Royal  Air  Force,  and  at  times  with  French,  Belgian, 
and  American  aviators.  I  have  made  many  friends 
among  them  all,  and  deeply  regret  the  loss  of  many 
who  have  "gone  west."  My  tribute  to  our  flying 
men  is  that  nothing  is  too  good  for  them,  and  tliat 
it  is  up  to  us  as  a  profession  to  strive  in  every  way 
we  can  to  save  them  from  disaster,  and  should 
disaster  overtake  them  to  find  the  means  to  restore 
them  to  health  again. 

The  Royal  Air  Force  Medical  Service  offers  excel- 
lent prospects  to  young  medical  men  who  have  not 
seen  much  of  the  world. 

It  is  to  be  hoped  that  the  experiences  recorded 
in  this  book  will  prove  of  some  value  to  others 
who  are  interested  or  engaged  in  similar  work. 

I  wish  to  express  my  thanks  to  Lord  Weir  for  the 
great  interest  he  has  taken  in  tliis  book,  and  for  his 
kindness  in  writing  the  introduction.  Fortune  has 
favoured  me  in  that  my  colleagues,  Lieut. -Colonel 
Flack,  R.A.F.,  and  Surgeon-Lieut.  Gotch,  R.N., 
have  each  contributed  chapters. 

Every  opportunity  to  carry  out  investigations  on 
the  medical  and  surgical  aspects  of  aviation  has 
been  afforded  me  by  the  commanding  officers  under 
whom  I  have  served,  namely  :  Wing-Comm.  C.  R. 
Samson,  R.N.A.S.,  Wing-Comm.  A.  W.  Longmore, 
R.N.A.S.,  Sqd.-Com.  P.  Shepherd,  R.N.A.S.,  Lieut.- 
Col.  C.  E.  H.  Rathbone,  R.M.L.I.,  Capt.  H.  D. 
Briggs,  R.N.,  and  Lieut.-Col.  F.  F.  Muecke,  R.A.F. 
Nor  can  I  forget  the  facilities  given  me  by  my  two 
Staff-Surgeons,  H.  V.  Wells  and  G.  D.  Bateman. 

But  my  greatest  debt  is  to  those  who  had  the 
patience  to  teach  me  to  fly,  Sqd.-Comm.  Hilton  Jones, 
R.N.A.S.,  Flight-Lieut.  Lloyd,  R.N.A.S.,  and  Flight- 
Comm.  McMinnies,  R.N.A.S.    To  the  latter  especially. 


during  two  years  of  association,  many  of  the  hours  of 
which  wire  spent  in  the  air  together,  I  have  to  express 
my  gratitude  for  his  vahiable  help  in  all  matters 
relating  to  aviation. 

My  warmest  thanks  are  cordially  given  to  Mr.  F.  F. 
Burohard  for  his  kindlv  encouragement  and  his  never- 
failing  advice  on  all  surgical  matters  ;  to  Surgeon- 
Lieut.  A.  G.  Holman,  R.X.,  for  furnishing  me  with 
notes  on  the  effects  of  cold  at  great  altitudes ;  to  Capt. 
Coler,  R.A.F.,  and  Capt.  Drake,  R.A.F.,  for  statistics 
and  reading  proofs  ;  to  Miss  Abbott  for  secretarial 
work  ;  and  to  Mr.  H.  E.  Powell,  Sub-Librarian  to 
the  Royal  Society  of  jNIedicine,  for  able  assistance  in 
collecting  the  literature  list. 

I  am  indebted  to  Major  Gamble,  R.A.F.,  for  many 
of  the  imique  photographs  of  aeroplane  a,ccidents  ; 
to  Dr.  Shenton  and  Miss  Thompson  for  the  X-Ray 
pliotographs,  and  to  Major  Lees-Smith,  R.A.F.,  and 
Lieut.  D.  G.  Brown,  R.A.F.,  for  other  illustrations. 
My  numerous  flying  friends  are  all  reminded  of  the 
important  part  they  have  played  in  helping  me  to 
lay  the  fruits  of  over  four  years'  work  with  them  at 
the  mercy  of  the  reader. 

H.  Graeme  Anderson. 

101,  Harley  Street, 
London,  W. 

November  5,  1918. 



Introduction     ......  xv 


I.     The  History  of  Medical  Interest 

IN  Aeronautics  and  Aviation   .  1 

II.     The   Selection   of  Candidates   for 

Aviation    .          .          .          .          .  16 

III.  The  Applied  Physiology  of  Aviation 

IV.  The  Psychology  of  Aviation          .  41 
V.     The  Aero-Neuroses         ...  67 

VI.     Aeroplane  Accidents      ...  96 

VII.     The  Surgery  of  Aviation       .          .  136 

VIII.     The      Injuries     and     Destructive 
Effects    of    Aeroplane     Bombs 

AND  Aeroplane  Arrows     .          .  207 

IX.     Aeroplane  Dope  Poisoning     .          .  222 

Glossary  of  Aviation  Terms     .  229 

Literature         ......  235 

Index           .....  241 



1.  A  seaplane  collided  with  and  stuck  in  the  mast  of  a 

large  Avireless  station.     The  pilot  was  saved 

2.  Probably  the  most  unique  aeroplane  accident  that  has 

ever  happened    . 

3.  An  aeroplane  caught  in  telegraph  wires — landed  on  one 

AA  ing  tip — occupants  uninjured 

4.  A  landing  in  the  tree  toj^s 
5a.  a  crash  in  a  forest  . 
5b.  An  imitation  of  hoM-  a  bird  lands  on  a  tree — pilot 


6.  A  nose  dive  into  a  wood    ..... 

7.  A  crash  between  hangars,  sho\\'Lng  difficulties  in  reach 

ing  the  injured  occupant      .... 

8.  A  crash  through  the  roof  of  a  hangar,   taken  from 

within        ...... 

0.     A  crash  between  land  and  water 

10.  A  crash  into  a  goods  train 

1 1 .  An  unique  landing — on  the  side  of  Dover  Castle 
12a.  Showing  result  of  flattening  out  too  late.     Aeroplane 

photographed  in  the  act  of  overturning — occupants 
uninjured  ........ 

12b.  Showing  result  of  flattening  out  too  soon,  and  pan- 
caking. Undercarriage  broken — occupants  un- 
injured      ........ 

13.  A  bad  crash,  showing  necessity  of  having  emergency 
tf)t)l  kit  to  cut  away  wreckage  and  reach  the  injured 
aviators     ........ 

1-t.  The  injured  should  not  be  dragged  out  from  the  wreck- 
age, but  the  latter  should  be  cut  away  first    . 

15.  An  aeroplane  crashed  and  on  fire        .... 

16.  Aeroplane  destroyed  by  fire  in  the  course  of  a  fe^v 

minutes     ........ 

17.  Triplex  goggles — the   resvdt  of  a 

pupil  escaped  injury  to  eyes 

18.  Triplex    goggles.     Right    lunette 

Aviator's  eye  escaped  damage 
IDa.  a  fatal  crash  .... 
19b.  Result  of  a  coUision  in  the  air 
£0.     A  crash  due  to  a  forced  landing 


crash  showing  how 
hit  by  shrapnel. 

















21a.  Fracture  through  neck  of  astragalus  .  .  ,  . 

21b.  Fracture    of    astragaUis.    CJompression    of    body    and 

fracture  through  neck  ..... 

22a.  Fracture  of  hody  of  astragalus  .... 

22b.  Fracture   of   body   of   astragalus   Avith   dislocation   of 

posterior  fragment      ...... 

23.  Fracture  of  body  of  astrajialus,  Avith  dislocation  fonvard 

and  outward  of  i^osterior  fragment 

24.  Fracture  of  body  of  astragalus,  with  dislocation  forward 

and  inward  of  anterior  fragment  .... 

25.  Chni  al   defoiiuity   of   Tahpes    Equino-Vams    due    to 

f  lacturc  of  lx)dy  of  right  astragalus  (Case  7)     . 

26.  Result  after  operation  of  total  astragalectomy,  right 

foot  (Case  7) 

27      ShoA\  ing  the  explosive  effect  of  a  large  aerial  bomb 










1.  A  typical  crash — occupants  uninjured.     Aeroplane  has 

to  be  sent  into  workshop  for  repairs       .  .  .        137 

2.  A  bad  landing — gentle  turn  over — occupants  uninjured 

— landing  wheel  broken        .....        138 

3.  A  crash,   result  of  flattening  out  too  late.     Machine 

overturned  and  wrecked       .....       151 

4.  Fatal  result,  due  to  crushing  effects    .  .  .  153 

5.  Showing  how  impact  injuries  occur.     A\aator's  head 

may  strike  cockpit  edge  or  instrument  board .  .       155 

6.  Showing  how  droAMiing  may  occur  as  result  of  seaplane 

crash  ........       156 

7.  Showing  how  suspension  effects  maj'  be  produced  if 

aviator  as  unable  to  loosen  his  safety  belt       .  .       157 

8.  Showing  in  v.  crash  in  a  tractor  machine  how  the  front 

seat  cockpit  gets  cnished      .....       158 

9.  Showing  how  the  pilot's  cockpit  escapes  crushing  effect       159 

10.  Aeroplane  on  fire  after  a  crash  .....       161 

11.  Showing  the  aeroplane's  nose  striking  the  ground  first, 

and  ho'\\'  the  abator's  feet  and  legs  are  likely  to  be 
injured       ...  .  .  .       176 

12.  Plating  of  right  femur.     Perfect  anatomical  and  func- 

tional result        .  .  .  .  .  .  .183 

13.  Showing  incision  parallel  to  Tendo -Achilles  for  removal 

of  posterior  fragment  ......       189 

14.  Skiagram  after  total  astragalectomy  .  .  .  .191 

15.  Showing  broken  propeller  blades  wliich  severely  injured 

a  mechanic  through  a  "  backfire  "...        195 

16.  Showing  a  sinking  seaplane  with  under  surface  of  main 

floats  now  uppermost  .....       203 

17.  Sho\\ing    result   of    "  waterbite "   to    both   feet,   nine 

months  after  occurrence       .....       205 

18.  Showing  to  left,  handle  and  fragments  of  percussion 

bomb  ;  to  right,  part  of  an  incendiary  bomb  .       208 

19.  Showing  a  crash  after  a  bombing  raid.     The  arrow 

points  to  an  unreleased  bomb        ....       209 

20.  Sho^\•ing    pieces    of    anti-aircraft    missiles    which    fall 

during  an  air  raid  and  may  produce  serious  injuries       217 


The  veil  which  has  covered  the  activities  of  the 
Royal  Air  Force  during  the  war  has  at  length  been 
lifted,  and  the  public  is  beginning  to  recognise  the 
immense  progress  in  aviation  which  has  been  made 
imder  the  intensive  cidtivation  of  the  last  four  years. 
From  the  facts  which  have  now  been  disclosed  it 
may  seem  that  the  conquest  of  the  air  has  been 
achieved,  both  for  military  and  commercial  purposes, 
but  the  actual  operation  of  aeroplanes,  more  especi- 
ally for  connnercial  purposes,  still  presents  difficul- 
ties which  are  not  perhaps  generally  recognised. 
Mechanical  development  has  in  fact,  to  some 
extent,  outstripped  what  may  be  called  operational 

The  wonderful  technical  progress  which  has  been 
made  during  the  wjir,  is  due  to  the  intimate  and 
whole-hearted  co-operation  of  the  aircraft  designers 
and  manufacturers  with  the  responsible  Government 

We  are  to-day  witnessing  the  birth  of  a  new  industry, 
concerning  itself  with  the  operation  of  aeroplanes 
for  commercial  purposes.  The  difficulties  which  the 
new  industry  will  have  to  meet,  I  am  convinced, 
can  be  successfully  overcome,  if  in  the  years  following 
the  war  this  spirit  of  mutual  confidence  and  of  co- 
operation is  maintained  between  the  industry  and 
the  Air  Ministry. 

Arising  out  of  this  development  of  the  commercial 
use  of  aeroplanes,  it  appears  that  among  the  responsi- 
bilities which  in  the  interests  of  the  public,  the  State, 



through  the  Ah'  Ministry,  wih  have  to  undertake, 
is  that  of  safeguarding  the  all  round  fitness,  both 
technical  and  medical,  of  the  commercial  pilot. 
Technical  fitness  can  be  secured  by  a  sound  system 
of  training.  Medical  fitness  is  more  dependent  on 
the  individual  himself,  but  as  has  been  discovered 
during  the  war,  a  great  deal  can  be  done  by  proper 
methods  of  selection,  supervision  and  physical  train- 

Great  as  is  the  importance  of  the  work  which 
has  been  carried  out  by  the  Medical  Authorities  of 
the  Royal  Air  Force  in  war  time,  it  seems  right  to 
forecast  that  it  will  prove  of  no  less  value  in  the  years 
of  peace.  An  account  of  the  methods  by  which  it 
has  been  developed  to  meet  the  special  needs  of  the 
Service,  will  be  found  in  Surgeon-Lieut.  Graeme 
Anderson's  book,  together  witli  the  review  of  our 
present  knowledge  and  practice  in  regard  to  the 
medical  and  surgical  aspects  of  flying  in  general. 
The  author  is  himself  a  pilot,  and  has  had  during 
the  war  an  extensive  experience  of  the  subject  on 
wliich  he  writes.  His  present  work  is  the  first  to 
deal  with  this  new  and  important  branch  of  medical 
study,  and  will  serve  to  stimulate  further  research 
into  the  many  and  varied  problems  which  still 
require   elucidation. 


January  11,  1919. 



The  History  of  Medical  Interest  in  Aeronautics 
AND  Aviation 

At  the  end  of  tliis  book  will  be  found  a  list  of  the 
literature  relating  to  the  medical  and  surgical  aspects 
of  aviation.  It  will  be  seen  by  the  comparatively 
large  number  of  contributions  and  contributors  how 
great  of  recent  years  has  been  the  interest  of  our 
profession  in  aviation. 

There  is  probably  no  doctor  with  such  a  wealth  of 
knowledge  of  aeronautics  and  aviation  from  the 
historical  point  of  view  as  Dr.  F.  J.  Poynton,  to  whose 
kindness  I  am  greatly  indebted  for  many  of  the  facts 
of  medical  interest  relating  to  ballooning.  In  1767  a 
physician,  Dr.  Black,  of  Edinburgh,  came  within  an 
ace  of  being  the  inventor  of  the  first  balloon.  He 
suggested  that  hydrogen  gas  would  be  capable  of 
raising  a  thin  bladder  in  the  air.  The  first  serious  study 
of  aeronautics  made  in  the  autumn  of  1783  was  marked 
l)y  investigations  on  strictly  scientific  lines,  in  that 
various  beasts  and  birds  were  sent  up  by  the  Mont- 
golliers  to  test  the  possibility  of  existence  in  the  air. 
At  Versailles  a  sheep,  a  cock,  and  a  duck  were  sent  up 
in  a  balloon  whieli  ascended  a  fc'w  hundred  feet  and 
came  down  half  a  mile  away.  These  animals  were 
found  none  the  worse  for  their  experience  except  that, 
K  1 


lor  some  unexplained  reason,  the  cock  was  found  to 
have  its  leg  broken.  In  the  Etiroj^ean  Magazine  of 
that  date  is  a  quaint  engraving  of  a  sheep  alighting 
after  a  flight,  to  the  joy  of  the  spectators  around. 

November  21,  1783,  saw  the  first  aerial  journey 
in  a  balloon  by  De  Rozicr  and  the  Marquis  D'Arlandes. 
They  ascended  to  3,000  feet,  but  in  the  account 
given  by  the  latter  no  mention  is  made  of  any 
physical  inconveniences  in  the  flight.  In  the  second 
aerial  join-ney,  however,  whicli  was  made  by  Charles 
and  Roberts  on  December  17,  1783,  these  pioneers 
ascended  to  6,000  feet  and  remained  up  for  one  and 
a  half  hours.  On  landing  Roberts  got  out  and 
Charles  alone  ascended  to  9,000  feet.  He  became 
benumbed  with  cold,  and  felt  severe  pain  in  the 
right  ear  and  jaw,  but  he  held  on  and  went  to  10,500 
feet.  This  is  the  first  record  of  pliysical  discomfort 
suffered  in  the  air. 

In  this  country  the  first  balloon  ascent  was  made  by 
a  Scotsman,  Tytler,  at  Edinburgh,  on  August  15, 1784. 
In  September,  1784,  the  Italian,  Lunardi,  became 
our  first  aerial  traveller.  The  first  Englishman  to 
go  up  was  a  surgeon,  John  Sheldon,  then  Professor 
of  Anatomy  at  the  Royal  Academy.  Full  of  scientific 
enthusiasm  he  accompanied  Blanchard  in  his  second 
balloon  ascent  in  England.  But  history  states  that 
science  was  thrown  to  the  winds,  and  that  the 
chief  concern  of  these  voyagers  was  to  reach  the  earth 
in  safety.  Although  no  facts  of  medical  interest 
were  recorded,  owing  no  doubt  to  the  good  doctor 
having  the  "  wind  up,"  it  is  gratifying  to  us  as  a 
profession  to  know  that  the  first  Englishman  to 
ascend  was  a  medical  man. 

On  January  7,  1785,  Dr.  Jeffreys,  an  American 
physician,  accompanied  Blanchard  in  a  balloon 
journey  across  the  English  Channel.  Ascending 
from  Dover  they  landed  in  France  in  the  forest  of 


Giiincs.  This  joiinu-y  was  also  undertaken  with 
scientific  ends  in  view,  and  among  the  gear  carried 
were  "  Letters  for  the  French,  philosophical  instru- 
ments, a  bottle  of  brandy,  biscuits,  and  two  cork 
jackets."  Unfortunately  during  the  flight  all  these 
had  to  be  cast  overboard  ;  and  it  is  even  recorded 
that  the  aeronauts  had  to  part  with  most  of  their 
clothing.  In  June,  1785,  an  attempt  was  made 
by  De  Rozier  and  Romain  to  cross  by  air  from 
France  to  England,  but  the  balloon  caught  fire  in 
mid-air,  and  both  aeronauts  perished. 

In  1785  another  medical  man.  Dr.  Fordyce, 
accompanied  Lunardi  in  his  balloon  flights  in  Scot- 
land, but  there  is  no  evidence  that  he  added  any 
observations  of  medical  interest  about  flying.  Blan- 
chard  in  1785  first  used  parachutes,  by  means  of 
wliich  he  lowered  dogs  from  balloons.  A  few  years 
later  he  made  a  parachute  descent  himself  and 
sustained  a  broken  leg. 

Almost  the  first  handbook  on  aeronautics  in  the 
English  language  was  the  Aerojxiidia,  by  BaldAvin, 
published  in  1786.  Although  he  was  not  a  medical 
man  Baldwin  heartily  recommended  balloon  ascents 
for  convalescents  in  the  following  words  : — "  The 
spirits  arc  raised  by  the  purity  of  the  air  and  rest  in 
a  chearful  composuiT."  In  conversation  Avith  a 
pre-war  balloonist  the  other  day  the  fact  was  elicited 
from  him  that  during  a  balloon  trip  all  worries  and 
mental  disturbances  disappeared  as  by  magic,  thus 
confirming  the  "  chearful  composure  "  described 
in  early  days,  l^aldwin  also  advised  scientific  in- 
vestigations of  "  tastes  and  odoiu's  at  different 
heights,"  and  commented  on  the  possibility  that  a 
change  "  from  hot,  putrid,  and  impure,  to  cool,  pure 
air,  imj:)r(gnatcd  witli  the  invigorating  aerial  acid, 
may  contribute  without  the  aid  of  drugs  to  the 
recovery   of   the    sick    and    invalid."     With    a   grim 


sense  of  humour  he  advised  ballooning  to  promote 

It  is  interesting  to  find  that  the  celebrated  American 
aeronaut,  John  Wise,  who  was  a  piano-maker  and 
suffered  from  dust  phthisis,  wrote  that  "  From  the 
devouring  ravages  of  such  a  complicated  disease 
the  practice  of  ballooning  relieved  me."  This  rather 
justifies  Baldwin's  advice,  although  it  is  recorded 
that  Lunardi  died  of  phthisis. 

As  to  the  therapeutic  value  of  flying,  the  future 
holds  great  possibilities.  Flammarion  records  that 
he  ascended  in  a  balloon  with  an  attack  of  influenza 
on  him,  and  that  when  he  came  to  earth  he  was 
completely  cured.  In  Hamel  and  Turner  one  reads 
that  a  gentleman  at  York,  while  suffering  from 
neuralgia,  made  a  passenger  flight  in  an  aeroplane, 
and  on  landing  foimd  that  the  pain  had  gone  ;  and 
that  H\ibert  Latham,  the  aviator,  suffered  from 
early  phthisis,  but  after  taking  up  aviation  enjoyed 
good  health.  The  sanatorium  airship  may  yet  have 
its  day.  There  is  no  doubt  that  flying  improves  the 
appetite  and  health  generally. 

As  a  rapid  means  of  rendering  first-aid  the  aero- 
plane is  invaluable.  The  author  was  the  first  to 
institute  this  method  of  travelling  to  aeroplane 
accidents,  and  has  now  made  between  thirty  and 
forty  such  journeys.  (See  Chapter  VI.)  The  French 
conceived  the  idea  of  having  aerial  ambulances  to 
convey  quickly  the  wounded — especially  gun-shot 
wounds  of  the  abdomen  and  chest — from  the  dressing 
posts  just  behind  the  firing  line  to  hospitals  well 
equipped  for  dealing  with  such  surgical  emergencies, 
and  situated  outside  the  range  of  hostile  artillery. 
Nemirovsky  and  Tilmant  have  lately  organised  an 
aeroplane,  which  they  have  named  the  "  Aerochir," 
to  carry  a  pilot,  a  surgeon,  and  a  radiographer  who 
can  also  act  as  assistant  surgeon,  as  well  as  an  equip- 


ment  consisting  of  an  X-Ray  apparatus,  a  steriliser, 
surgical  instruments,  accessories  and  dressings.  The 
electric  current  from  the  aeroplane  can  be  used,  with 
the  addition  of  a  transformer  and  an  interrupter, 
to  work  the  X-Ray  apparatus,  and  also  the  steriliser. 
The  following  advantages  are  claimed  for  the  "  Aero- 
chir  "  : — (1)  That  by  its  means  surgical  aid  can  be 
brought  quickly  ;  (2)  The  surgeon  is  brought  to  the 
patient  and  the  latter  saved  a  journey  before  receiving 
surgical  aid  ;  (3)  It  does  not  increase  traffic  on  roads 
required  for  purely  military  purposes  ;  and  (4)  For- 
mations of  these  aeroplanes  can  rapidly  transfer 
surgical  aid  from  one  part  of  the  line  to  another 
where  an  attack  may  have  suddenly  occurred. 
In  future  wars,  with  the  possibility  of  large  formations 
attacking  each  other,  one  may  find,  hovering  on  the 
outskirts  of  a  battle  royal  in  the  air,  first  aid  aero- 
planes, surgically  equipped,  distinguished  by  the 
Red  Cross,  and  each  carrying  a  surgeon  and  sick 
berth  attendant,  ready  to  follow  down  and  render 
aid  to  a  fallen  aerial  combatant. 

With  regard  to  the  effects  of  altitude  on  the  human 
body  it  is  interesting  to  study  the  first  accounts 
amongst  the  balloonist s.  At  Hamburg,  early  in  1800, 
Robertson,  with  a  companion,  in  a  balloon  ascent  to 
21,500  feet,  suffered  altitude  effects.  The  chest  felt 
enlarged,  voices  became  almost  inaudible,  and  there 
were  noted  ear  trouble,  swelling  of  the  lips,  promi- 
nence of  the  eyes,  and  epistaxis.  The  Russian  aurist, 
Sakaroff,  accompanied  Robertson  on  one  of  his 
trips,  and  made  scientific  observations.  In  1800 
Gay-Lussac  and  Biot,  in  a  balloon  ascent  in  France, 
were  similarly  affected.  The  height  reached  was 
23,000  feet,  and  Lussac  was  affected  by  the  cold  ; 
his  fingers  became  benumbed,  he  had  laboured 
breathing,  a  quickened  pulse,  parched  throat,  and 
headache.     In    the    same    year    Count    Zambeccari, 


Dr.  Grassati,  and  M.  Andreoli  made  an  ascent  to  a 
high  altitude,  and  the  two  former  became  uncon- 
scious. They  noted  the  inaudibiUty  of  their  voices 
at  great  heights,  and  also  the  effects  of  cold.  They 
suffered  severely,  and  were  nearly  frozen  to  death 
over  the  Adriatic. 

These  seem  to  be  the  first  records  of  altitude 
effects  on  the  body,  and  the  train  of  signs  and 
symptoms  were  ki  own  under  the  name  of  balloon 
sickness.  Madame  Blanchard  suffered  from  severe 
epistaxis  at  22,800  feet.  The  first  detailed  records 
of  altitude  effects  are  gathered  from  the  historic 
ascent  of  Glaisher  and  Coxwell  to  31,000  feet.  The 
former's  records  show  that  at  18,844  feet  his  pulse 
was  quickened  to  100 — at  19,415  feet  his  breathing 
was  affected  and  he  had  palpitation — at  19,435  feet 
his  pulse  was  quicker,  liis  hands  and  lips  bluish  in 
coloiu',  and  he  eoidd  with  difficulty  read  the  instru- 
ments— at  21,792  feet  he  suffered  from  sea  sickness, 
although  there  was  no  rolling  or  pitching  of  the 
balloon,— at  24,000  he  became  unwell— at  29,000 
feet  he  had  great  muscular  weakness ;  he  says, 
"  I  seemed  to  have  no  limbs,"  and  then  he  fell  back 
insensible  for  seven  minutes.  Coxwell's  hands 
became  frostbitten,  he  was  attacked  by  great  weak- 
ness in  the  limbs,  but  managed  to  open  the  balloon 
valve  by  pulling  on  the  valve  cord  with  his  teeth, 
and  thus  to  save  the  situation  for  both.  On  descend- 
ing recovery  seems  to  have  been  very  rapid,  as 
shortly  afterwards  both  aeronauts  were  able  to  walk 
about  seven  miles. 

Gaston  Tissandier,  Sivel,  and  Croce-Spinelli  all 
suffered  from  altitude  effects.  Prominent  among 
the  signs  and  symptoms  were  difficulty  in  breathing, 
loss  of  muscular  power,  venous  congestion,  nasal 
and  pulmonary  haemorrhage,  headache,  vomiting 
and    torpor.     Even    death    has    resulted,    and    both 


Sivcl  and  Croce-Spinelli  met  their  fate  in  this  manner. 
Siveh  in  1875,  when  at  23,000  feet,  wrote,  "  I  am 
inhahng  oxygen,  the  effect  is  excellent."  At  25,000 
feet  Tissandier  wrote,  "  I  feel  stupefied  and  frozen, 
Croce-Spinelli  is  motionless  in  front  of  me  ;  the 
mind  and  body  weaken  by  degrees  and  imperceptibly 
without  consciousness  of  it  ;  no  suffering  is  then 
experienced,  on  the  contrary  an  inner  joy." 

Dr.  A.  Berson  in  1894  ascended  to  30,000  feet, 
was  aloft  five  hours,  but  inhaled  oxygen  all  the 
time  and  was  unaffected.  Other  physical  illnesses 
have  been  recorded  as  occurring  in  the  air  ;  it  is 
said  that  Blanchard  was  seized  with  an  apoplectic 
stroke  diu'ing  an  ascent ;  in  1824  Lieut.  Harris,  R.N., 
and  Miss  Stocks  made  a  rapid  balloon  descent ; 
the  former  was  killed,  but  the  latter  fainted  and 
escaped  without  injury.  Her  nerve  was  not  affected, 
and  she  made  three  subsequent  ascents.  Observa- 
tions of  medical  interest  on  the  influence  of  air 
pressure  on  the  ear  were  made  by  Alt  in  a  balloon 
ascent.  He  examined  his  companion's  ear  during  the 
flight,  and  verified  the  decrease  in  the  power  of  hear- 
ing and  such  symptoms  as  pain  and  buzzing  in  the 
ears.  He  noted  that  the  tympanic  membrane 
became  congested  and  was  pushed  back  during  the 

These  early  pioneer  aeronauts  are  to  be  greatly 
atlmired  for  their  courage,  and  to  them  are  due 
majiy  facts  of  fundamental  importance  in  the 
medical  study  of  aeronautics.  They  showed  us 
tlic  qualities  and  daring  temperament  necessary 
for  the  successful  aviator,  the  possibility  of  the 
hunuiii  body  withstanding  flight  in  mid-air  and 
the  endurance  of  long  flights  (Green  in  his  famous 
lligiit  from  London  to  Germany  was  eighteen  hours 
aloft),  and  they  also  gave  us  our  first  records  of 
altitude  effects  on  the  human  body.     It  is  gratifying 


to  note  the  prominence  taken  by  medical  men  in 
these  early  ascents.  The  names  of  three — Dr.  Shel- 
don, Dr.  Jeffreys,  and  Dr.  Fordyce — should  go  down 
in  history  as  the  forefathers  of  our  R.A.F.  medical 
service.  Another  medical  man  should  be  men- 
tioned. Dr.  McSweeny,  who,  although  he  gave  us 
no  facts  of  medical  interest,  wrote  an  essay  in  1844 
on  aerial  navigation  and  practical  ballooning. 

Many  investigations  have  been  carried  out  on  the 
effects  of  altitude  on  human  and  animal  life.  In 
Peru  in  1890  Viault  noted  an  increase  in  the  number 
of  red  blood  cells  at  great  mountain  heights.  This 
was  verified  in  1901  by  Gaule  in  a  balloon  ascent. 
Abderhalden  in  1902  investigated  the  influence  of 
high  altitude  on  the  blood  of  rabbits — and  on  Pike's 
Peak  similar  investigations  were  carried  out  on  the 
human  body  by  Haldane,  Douglas,  Henderson  and 
Schneider.  Armand  Delille,  Andre  Mayer,  and  Jolly 
demonstrated  that  no  change  occurred  in  the  blood 
from  the  heart  in  high  altitudes,  but  that  the  peri- 
pheral blood  alone  showed  polycythaemia.  Victor 
Henri  investigated  the  effects  of  altitude  on  the 
gases  of  the  blood.  Hallion  and  Tissot  studied 
arterial  pressure  and  respiratory  changes  in  relation 
to  high  altitude.  Dreyer  and  Ainley  Walker,  in  the 
Lancet  of  October  25,  1913,  discussed  the  effect  of 
altitude  on  blood  volume. 

Mention  must  be  made  of  the  work  done  on  alti- 
tude effects  by  Mosso  and  by  Aggazotti  in  Italy  ; 
and  also  of  the  investigations  on  mountain  sickness 
carried  out  by  the  Germans  Zuntz,  Duric,  and  col- 
leagues. But  the  wonderful  researches  of  that 
famous  physiologist,  Paul  Bert,  on  the  effects  of 
diminished  atmospheric  pressure  have  remained  since 
that  time  (the  seventies)  as  the  basis  of  all  subsequent 
work  on  altitude  effects. 

Iq  the  time  intervening  between  ballooning  and 


aviation  came  the  period  of  the  oliders,  in  which 
man  made  his  first  attempt  to  fly,  using  an  apparatus 
heavier  tlian  air.  These  ghdes  or  flights  Avere  made 
from  hillsides,  from  specially  constructed  towers, 
and  from  balloons.  This  period,  which  heralded  the 
birth  of  aviation,  gave  us  no  facts  of  medical  interest 
save  the  study  of  the  psychology  of  these  daring 
gliders,  and  the  surgical  disabilities  which  resulted 
from  their  daring.  Nevertheless  it  will  be  found  of 
value  to  study  the  work  of  those  pioneer  gliders, 
Montgomery,  Lilienthal,  Pilcher  and  others.  From 
1891  till  1896,  when  he  met  his  death  in  a  gliding  trial, 
Lilienthal  made  many  glides,  and  a  study  of  his 
writings  is  peculiarly  interesting  from  the  psj^cho- 
logical  point  of  view.  Once  in  a  gliding  experiment 
he  fell  65  feet  to  earth,  and  he  writes  thus  :  "  With 
my  senses  quite  clear,  my  arms  and  my  head  forward, 
still  holding  the  apparatus  firmly  with  my  hands, 
I  fell  towards  a  greensward  ;  a  shock,  a  crash,  and 
I  lay  with  my  apparatus  on  the  ground."  And 
again,  "  I  often  reach  positions  in  the  air  which  are 
much  higher  than  my  starting  point.  At  the 
cliinax  of  such  a  line  of  flight  I  sometimes  come  to 
a  standstill  for  some  time,  so  that  I  am  enabled 
whilst  floating  to  speak  with  the  gentlemen  who 
wish  to  photograph  me  regarding  the  best  position 
for  the  photographing."  These  last  few  lines  reveal 
to  the  autlior  more  than  anything  else  the  psychology 
of  these  pioneer  aviators.  It  was  Lilienthal's  death 
in  a  gliding  accident  in  1896  that  caused  the  Wright 
brothers,  four  years  later,  in  1900,  to  begin  their 
researches  on  aviation,  which  culminated  in  the  first 
aeroplane  flight  on  December  17,  1903.  From  that 
historic  date  others  took  up  the  new  art,  notably 
Henri  Farman  and  Leon  Delagrange  ;  and  in  the 
year  1908  w(;  find  aviation  well  established. 

The  first  Englishman  to  fly  was  Moore  Brabazon, 


in  1909.  Thv  Services  took  up  aviation  in  1912 
witli  the  establishment  of  the  Royal  Flying  Corps 
and  a  naval  wing — the  latter  destined  to  become  the 
Royal  Naval  Air  Service,  now  of  happy  memory. 

From  1903  till  1907  the  author  can  find  no  records 
of  medical  interest  in  aviation.  In  1907  there  was 
published  in  Paris  a  pamphlet  of  five  pages  by  Dr. 
Xaquet,  entitled  :  Physiologiques  {quelques  Con- 
siderations generals  et)  siir  les  Ascenscionnistes,  Aero- 
nautes,  et  ^Iviateurs. 

During  the  Circuit  de  I'Est  in  1910  in  which  the 
contestants  were  compelled  to  fly  regardless  of 
weather,  the  German  Lindpainter  had  to  give  up 
because  of  physical  and  nervous  exhaustion  ;  and 
another  candidate  on  alighting  crawled  under  his 
machine  and  went  to  sleep.  In  1910  Moulinier,  in 
France,  investigated  the  arterial  tension  among 
aviators  at  high  altitudes.  In  1911,  in  France, 
Cruchet  and  ^loulinier  published  their  findings  on 
arterial  tension,  altitude,  and  aviator's  sickness ; 
Bonnier  recorded  his  investigations  on  the  "  Capacite 
manostatique "  among  aviators ;  Reymond  wrote 
on  the  reflexes  in  aviation,  and  Rouch  on  aviation 
schools  and  military  medicine.  In  Italy  work  was 
published  in  the  same  year  by  Falchi  and  Nicddu- 
Semidei,  and  in  Russia  by  Prof.  B.  Okouneff  on  the 
aural  question  in  relation  to  aviation.  Some  military 
balloonists  had  consulted  the  latter  on  deafness  due 
to  ascents,  and  subsequent  compensation.  Hence 
his  investigations  into  the  effects  of  rarefied  air  on 
the  organs  of  hearing.  The  only  article  of  medical 
interest  in  aviation  in  this  country  appeared  in 
Flight  on  May  6,  1911,  by  F.  I.  Wilbur,  entitled, 
"  Aviation  and  Common-sense." 

With  the  formation  of  the  Naval  and  Military 
Wings  of  the  Royal  Flying  Corps  in  1912,  two  Service 
medical    officers    were    appointed,    namely  :     Staff- 


Surgeon  H.  V.  Wells,  R.X.,  to  the  Naval  ^Ving^  and 
Captain  E.  G.  R.  Lithgow,  R.A.M.C.,  to  the  Military 
AVing.  Both  were  happy  selections,  as  these  doctors 
developed  a  keen  interest  in  practical  aviation  ;  and 
it  is  to  their  credit  that  they  were  the  first  medical 
men  in  this  coujitry  to  learn  to  fly.  Lithgow  obtained 
his  Royal  Aero  Club  Aviator's  Certificate,  No.  il4,  on 
February  -1,  1913,  at  Upavon  on  a  Short  biplane, 
whilst  \Vells  obtained  his,  No.  490,  on  May  24,  1913, 
on  a  Bristol  biplane  at  Eastchurch. 

The  year  1912  also  srw  work  in  France  by  Crouzon 
on  arterial  tension,  and  by  Marquis  on  practical 
hygiene  of  the  aviator  and  aeronaut  :  in  Italy  by 
Falchi,  and  the  first  German  contributions  by 
Flennning  and  by  von  Schrotter.  In  1913  we  find 
in  this  country  Wells  laying  the  foundation  of  his 
work  to  be  published  later,  and  the  late  Dr.  Adler 
doing  the  same  by  making  flights  with  Hamel.  In 
France  a  paper  was  read  by  Dr.  Reymond,  a  senator, 
at  the  Paris  Congress,  in  which  he  comments  on  the 
effects  of  flying  on  cardiac  disease  and  pulmonary 
tuberculosis,  pointmg  out  how  badly  the  emphy- 
sematous and  asthmatic  suffer  through  flying,  giving 
hints  on  clothing  and  hygiene,  and  predicting  the 
great  possibilities  in  the  medical  investigations  into 
flying  ;  a  small  article  by  Legrand  completes  the 
French  contributions  for  that  year.  In  the  same 
year  there  were  articles  by  Cowley  in  Havana 
and  by  Friedlander,  Huss,  and  Von  Schrotter  in 

In  1914  the  late  Dr.  Adler  published  the  first 
article  in  this  country  on  the  medical  aspects  of 
aviation  in  a  separate  chapter  in  Hamel  and  Turner's 
book  on  Flying,  although  it  must  be  remembered 
that  Wells  had  really  commenced  before  him,  and 
also  had  his  first  paper  completed,  although  not 
published.     In  this  year  also  we   find  the  first  eon- 


tribution  from  America  in  Ovington's  letter  on 
"  the  psychic  factor  in  aviation."  In  Germany  con- 
tributions were  made  by  Halben,  Koschel,  Loewy 
and  Placzek,  Marx,  Suring,  and  Volkmann. 

Just  after  the  outbreak  of  war  the  author,  in 
association  with  Wells,  investigated  the  injuries  and 
destructive  effects  of  aeroplane  bombs  in  Belgium 
and  France.  Early  in  1915  Wells  embodied  the  re- 
sults of  his  invest  gations  of  1912-1913  in  an  article 
on  "  The  Flying  Service  from  a  Medical  Point  of 
View,"  which  was  published  in  the  Journal  of  the 
R.X.  Medical  Service.  In  this  he  discussed  the 
questions  of  high  velocity  accidents,  safety  belts, 
safety  helmets  and  clothing,  and  dealt  with  the 
physical  requirements  of  candidates  for  the  flying 
service.  He  found  that  the  researches  into  pulse 
rate  and  blood  pressure  were  unsatisfactory  during 
flight,  owing  mostly  to  the  vibrations  of  the  aeroplane 
affecting  the  pressure  recording  instruments. 

Willcox,  Spilsbury,  and  Legge  published  the  results 
of  their .  investigations  on  aeroplane  dope  poisoning. 
In  Germany  an  article  by  Schoppler,  of  medical  interest 
appeared.  In  the  latter  half  of  1915  the  author 
was  investigating  aeroplane  accidents. 

The  year  1916  saw  another  communication  by 
Wells  on  "  Some  Aeroplane  Injuries  and  Diseases, 
with  Notes  on  the  Aviation  Service."  In  this  he 
dealt  with  injuries  to  the  neck  and  eye  in  aeroplane 
accidents,  and  cautioned  against  the  danger  of 
sending  an  apparently  unhurt  aviator  into  the 
air  again  immediately  after  a  crash  to  prevent  loss 
of  nerve  ;  he  gave  a  detailed  account  of  a  case  of 
frost  bite  occurring  in  an  aviator  at  15,000  feet  in 
winter  time  ;  he  commented  on  the  question  of  ill 
effects  from  petrol  vapour  and  exhaust  gases  to  the 
aviator  during  flight ;  he  described  the  nervous 
breakdowns  of   flying  pupils   and   coined  the   word 


"  Aerosthcnia  "  to  cover  these  conditions  ;  and  he 
touched  on  the  importance  to  the  pilot  of  eyesight 
and  free  joint  movements  of  the  lower  limbs.  In 
this  country  also  Knott  published  an  article  on 
aviators'  sickness,  while  from  American  sources 
came  a  contribution  from  Holloway  and  one  from 
Cottle,  a  medical  officer  of  the  U.S.  Xavy,  on  "  Naval 
Aviation  Personnel."  Splendid  work  was  also  done 
in  Paris  by  Camus,  Nepper,  and  Binet  on  the  reaction 
times  of  aviators  and  on  the  physiological  reactions 
to  various  shocks  as  a  means  of  picking  out  the  best 
aerial  fighters  ;  while  in  France  also.  Ferry  published 
an  interesting  article  on  an  experimental  study  of 
arterial  tension  in  aviators,  and  articles  came  from 
the  pens  of  Vorbe  and  Rocher. 

In  191G,  Captain  Halliwell,  C.A.M.C.,  graduated 
as  a  flying  officer,  and  did  war  flying  as  an  active 
service  pilot.  He  is  the  only  medical  man  of  our 
empire  who  has  earned  this  distinction,  although 
some  medical  students  were  active  service  pilots,  and 
one  at  least  has  since  qualified  as  a  doctor.  The 
author  obtained  the  Royal  Aero  Club  Aviator's 
Certificate,  No.  3758,  on  October  26,  1916,  at  East- 
bourne, on  a  Maurice  Farman  biplane. 

In  October,  1916,  there  was  formed  a  special 
Medical  Board  of  the  R.F.C.,  consisting  of  Dr.  G.  A. 
Sutherland,  Mr.  A.  H.  Cheatle,  and  Major  Lithgow, 
to  deal  witli  the  medical  selection  of  flying  officers 
and  also  with  invaliding  and  disposing  of  those 
injured  or  broken  down.  1917  was  a  year  of  great 
developments.  Many  contributions  to  the  literature 
on  the  medical  aspects  of  aviation  ^vcYc  made  by 
American  writers,  notably  those  by  Small  and  by 
Blaauw  oji  visual  requirements,  by  Chamberlain, 
Connor,  and  Green  on  medical  examination  standards  ; 
by  Babc(X'k  on  Jiarany  tests,  and  by  Jones  and 
Guggenheim    on    otology    in    relation    to    aviation. 


Lacroix,  in  France,  contributed  an  article  on  otology, 
and  Genielli  in  Italy  one  on  blood.  Dclapchicr,  in 
France,  was  the  first  to  record  a  case  of  fracture  of 
the  astragalus  in  a  parachute  descent. 

The  R.F.C.  Special  Medical  Board  did  splendid 
"Nvork  and  had  to  be  considerably  augmented.  Major 
Lithgow's  long  experience  of  aviation  was  of  very 
considerable  value  on  the  invaliding  board,  and 
notable  work  was  done  by  Cheatle  in  the  elabora- 
tion and  application  of  various  tests  to  determine 
the  neuro-muscular  stability  of  aviators,  and  by 
Sutherland  on  the  investigation  of  cardio-vascular 
debility  in  those  who  had  broken  down  through 
stress   of   flying. 

Early  in  1917  a  meeting  took  place  between  the 
naval  medical  authorities  interested  in  aviation, 
the  R.F.C.  special  medical  board,  and  a  body  of 
medical,  pliysiological,  and  technical  experts.  Various 
medical  aspects  of  aviation  were  discussed,  and 
standards  of  vision  and  fitness  for  flying  were  drawn 
up.  In  April,  1917,  Martin  Flack,  from  the  Medical 
Research  Committee,  was  appointed  adviser  on  re- 
search connected  with  the  physiological  aspects 
of  flying.  The  value  of  his  work  cannot  be  over- 
estimated, and  has  proved  of  very  great  help  in  the 
selection  of  candidates  for  aviation,  and  in  deter- 
mining those  who  are  on  the  point  of  showing  fatigue 
and  suffering  through  stress  of  flying. 

In  France  Major  Birley,  R.A.M.C.,  was  super- 
intending all  the  R.F.C.  in  the  field.  In  the  same 
country  the  author  Avas  attached  to  a  large  flyuig 
school  where  unique  opportunities  were  afforded  in 
the  study  of  the  flying  pupil,  and  where  also  the 
author  carried  out  his  "  blindfold  "  experiments 
in  the  air  to  test  the  sense  of  balance  in  flight.  The 
last  item  of  medical  interest  in  1917  was  the  forma- 
tion   of    a    Central    Air    Hospital    for    investigating 


the  ailments  of  both  naval  and  military  flying 

The  present  year,  1918,  has  been  historic  in  that 
it  has  witnessed  the  fusion  of  the  Royal  Naval  Air 
Service  and  the  Royal  Flying  Corps  into  a  single 
service,  namely,  the  Royal  Air  Force.  Accompany- 
infT  this  has  been  the  formation  of  a  new  Air  Force 
M(  dical  Service.  Under  the  able  command  of  Lieut. - 
Colonel  F.  F.  Muecke,  R.A.F.,  the  Central  R.A.F. 
Hospital  has  now  become  well  established,  and 
many  auxiliary  hospitals  have  been  attached  to  it. 

In  an  address  to  the  Medical  Society  of  London 
on  March  11,  1918,  on  the  selection  of  candidates 
for  the  Air  Service,  the  author  suggested  the  forma- 
tion of  a  special  medical  flying  school  where  the 
standards  of  fitness  demanded  of  the  aviator  could 
be  put  to  the  test,  and  where  also  certain  "  border 
line  "  cases  of  pupils  turned  down  from  flying  could 
be  investigated.  This  has  since  been  carried  out, 
and  there  valuable  work  has  been  done  by  Captain 
Rippon,  R.A.M.C.,  Dr.  Head,  and  Dr.  Rivers. 

Mention  must  also  be  made  of  the  good  work  carried 
on  all  along  by  Dr.  Atkin  Swan  and  his  colleagues 
at  the  R.F.C.  hospitals.  In  1918  four  more  medical 
men  have  learnt  to  fly,  namely  : — Captain  Tredgold, 
R.A.M.C,  Captain  Hearn,  R.A.M.C.,  Lieut. -Colonel 
Ileald,  R.A.F.,  and  Lieut.-Colonel  Taylor,  R.A.F. 
The  year  has  produced  many  contributions  of  medical 
interest  to  the  literature  l)y  French,  American,  and 
British  writers. 


The  Selection  of  Candidates  for  Aviation 

The  Development  of  Aviation 

All  will  agree  that  one,  ii"  not  the  outstanding, 
feature  of  this  present  war  has  been  the  remarkable 
development  of  aviation.  Scarcely  ten  years  ago 
the  pioneer  aviators  were  looked  upon  as  men 
possessing  some  supernatural  quality — the  power 
to  fly.  Then  man  began  to  teach  man,  and  the 
institution  of  dual  control  instruction,  in  which 
teacher  and  pupil  fly  in  the  same  aeroplane,  each 
with  a  set  of  controls  acting  in  unison,  paved  the 
way  for  man}"  to  learn  flying.  The  services — naval 
and  military— organised  flying  corps,  and  the  possi- 
bilities of  this  new  arm  in  warfare  were  seriously 
considered.  On  the  outbreak  of  war  the  personnel 
of  the  Air  Service  was  increased,  and  there  was  a 
great  demand  for  pilots.  As  loss  and  wastage 
occurred  this  demand  grew  and  methods  of  training 
in  flying  were  intensified.  Accompanying  this  have 
been  the  development  in  aeroplanes  of  speed,  power, 
and  construction,  and  the  institution  of  long-distance 
flights,  high  altitude  flying,  night  flying,  and  special- 
isation in  different  forms  of  flying — e.g.,  aerial  fighting, 
reconnaissance,  and  photography,  bombing,  testing, 
and  instructing. 

The  Aviator's  Duties 

To  realise  the  value  of  the  standards  of  fitness 
required  it  is  well  to  know  something  of  the  avi- 
ator's duties  in  war-time.     On  the  one  hand,  he  has 



usually  comfortable  quarters,  a  good  bed  and 
food,  and  has  not  to  undergo  the  long  marches  and 
discomfort  of  trench  life  as  in  the  infantry  work. 
He  is  usually  out  of  range  of  enemy  artillery  fire, 
although  subject  to  hostile  aircraft  attack.  In 
weather  unfit  for  flying  he  has  much  leisure  time. 
On  the  other  hand,  in  the  few  crowded  hours  of 
his  daily  work  he  may  come  through  the  most  intense 
strain  to  which  the  human  nervous  system  can  be 
subjected.  As  it  has  been  aptly  put,  an  aviator's 
life  consists  of  "  long  spells  of  idleness  punctuated 
by  moments  of  intense  fear."  He  has  to  face 
extremes  in  the  elements,  intense  cold,  the  sun's 
glare,  rain,  wind,  fog  and  mist,  and  gusty  or  bumpy 
weather.  There  is  the  incessant  noise  of  his  engine  ; 
he  may  have  long-distance  patrols,  in  which  the 
imagination  is  given  free-play  to  run  riot,  perhaps 
over  the  sea,  with  no  landmarks  and  the  dread  of 
engine  failure  ever  present  in  his  mind.  His  visual 
acuity  is  sharpened,  always  on  the  look-out  for 
hostile  aircraft,  watching  for  and  registering  the 
flash  of  enemy  guns,  taking  photographs,  noting 
movements  of  enemy  troops,  rolling-stock,  sub- 
marines, or  other  information  of  naval  or  military 
value,  and  subjected  to  more  or  less  accurate  anti- 
aircraft gun  fire  from  the  ground.  Often  he  has  to 
reach  altitudes  where  the  available  oxygen  is  reduced 
by  one-half.  He  may  have  suddenly  and  rapidly 
to  change  height,  as  in  the  modern  aerial  fight  in 
whicii  he  may  be  opposing  more  than  one  enemy 
machine.  His  judgment  has  to  be  most  accurate 
to  perform  the  various  intricate  aerial  evolutions 
so  as  to  outwit  his  opponent  and  gain  a  favourable 
position  to  rake  him  with  machine-gun  fire.  He 
may  have  to  loop,  spin,  dive,  or  side-slip,  apparently 
out  of  control,  in  order  to  deceive  his  opponent 
or  to  decoy  him  over  a  friendly  gun  or  near  a  friendly 


formation.  There  is  the  subconscious  dread  of  his 
aeroplane  catching  fire  in  the  air.  Lastly,  and  most 
exciting  of  all,  is  the  nerve-strain  of  contour  chasing 
or  ground  strafing,  in  which  he  attacks  the  enemy  on 
the  ground  from  a  low  height  of  perhaps  20  to  50  feet. 

Basis  of  Present  Investigation 

With  regard  to  the  views  to  be  expressed  on  the 
standards  of  fitness  for  such  work,  these  are  not  to 
be  taken  as  representative  of  any  particular  Service. 

We  can  help  in  framing  standards  of  fitness  for 
flying  by  knowing  the  requirements  of  the  aviator's 
life,  by  studying  the  psychology  and  physiology  of 
flying,  and  by  investigating  the  maladies  commonly 
found  among  flying  men.  By  such  means  stand- 
ards of  fitness  can  be  drawn  up  subject  to  modifica- 
tion from  time  to  time.  In  eliminating  the  imfit 
the  author  would  suggest  the  institution  of  a  special 
flying  school  where  border-line  pupils  could  be 
instructed  in  flying  under  patient  and  sympathetic 
instructors  and  with  a  medical  officer,  specially 
interested  in  aviation,  carefully  recording  the  results. 
Such  records  would  be  invaluable  to  us  in  confirming 
or  modifying  the  present  standards  of  fitness  required 
for  air  work.  The  modern  aviator's  work  is  becoming 
more  and  more  specialised,  and  here  again  we  can 
help  by  framing  standards  of  fitness  graded  for  the 
various  flying  duties. 

Physical  Requirements 

In  selecting  candidates  for  the  Air  Service  what  is 
looked  for  is  a  sound  constitution,  free  from  organic 
disease,  and  a  fairly  strong  physique  in  order  to 
withstand  altitude  effects,  such  as  cold,  fatigue,  and 
diminished  oxygen.  It  is  essential  there  should  be 
normal  hearing  and  good  muscle  and  equilibration 


Eyesight. — As  the  aviator  is  so  dependent  on 
his  eyesight,  too  much  importance  cannot  be  attaclied 
to  this  part  of  the  examination. 

Temperament. — But  next  to  vision,  and  most 
important  of  all  in  obtaining  the  best  aviator,  is  the 
question  of  temperament.  Undoubtedly  there  is  a 
particular  temperament  or  aptitude  for  flying,  and 
its  distribution  is  peculiarly  interesting,  whether 
looked  upon  from  its  racial  aspect  and  ethnological 
origin  or  in  relation  to  previous  health,  life,  and 
habits.  Unfortunately,  this  temperament  is  a  diffi- 
cult matter  to  estimate  clinically,  and  especially  so 
in  the  examining  room.  The  ideal  aviator  must 
have  good  judgment,  be  courageous,  and  not  upset 
by  fear,  although  conscious  of  the  perils  of  his  work. 
He  must  be  cool  in  emergencies,  able  to  make  careful 
and  quick  decisions  and  act  accordingly.  His  reac- 
tion-times must  never  be  delayed — he  must  be  ever 
ale-rt,  as  mental  sluggishness  in  flying  spells  disaster. 
AMiether  he  should  be  imaginative  or  not  is  a  difficult 
question  to  settle — one  meets  many  of  both  types. 
The  author  is  inclined  to  think  the  individual  with 
imagination,  yet  able  to  keep  it  well  under  control, 
makes  the  better  pilot. 

Previous  Training  in  Sports. — With  regard  to  rela- 
tion of  habits  in  this  special  aptitude  for  flying,  the 
latter  is  found  most  commonly  among  those  used 
to  playing  games  and  leading  an  outdoor  life.  The 
yachtsman  and  the  horseman,  with  their  finer  sense 
of  judgment  and  "  lighter  hands,"  should  make  the 
most  skilful  pilots.  The  Germans  until  recently 
always  selected  their  aviators  from  their  cavalry. 
It  was  thought  that  the  racing  motorists  would 
make  the  best  pilots,  but  this  has  not  always  been 
proved  to  be  so.  Every  now  and  then  one  meets 
the  type  with  splendid  physique  and  apparently 
imshakable  courage  and  finds  that  he  learns  to  fly 


indifferently  or  is  unable  to  learn  at  all,  and  again 
one  meets  the  weedy,  pale  type  learning  quickly  to 
fiy  and  turning  out  to  be  a  first-rate  pilot. 

Family  and  previous  History. — In  estimating  whether 
the  candidate  is  likely  to  stand  the  strain  of  war- 
time flying  much  help  can  be  given  by  inquiring 
into  his  family  history  as  well  as  the  history  of  his 
previous  health. 


Candidates  for  the  Air  Service  should  be  made  to 
undergo  (1)  a  surgical  examination,  (2)  a  medical 
examination,  and  (3)  a  special  sense  examination, 
preferably  by  experts  in  each  line  ;  the  final  selection 
should  be  made  on  the  total  results  by  a  medical 
selection  committee. 

(1)  Surgical  Examination. 

General. — In  the  surgical  examination  the  age, 
height,  weight,  and  general  physique  are  considered. 

Age. — The  age  should  be  between  18  and  30  years. 
Under  18  and  up  to  20  caution  and  well-balanced 
judgment  may  be  lacking  ;  24  is  about  the  best  age. 
Over  33  the  candidate,  although  quite  able  to  learn 
to  fly,  does  not  stand  the  nerve-strain  of  air  work 
so  well.  Much  depends  on  the  physiological  age. 
Cody  learnt  flying  at  47  and  was  flying  regularly 
till  he  met  his  death  when  52  years  of  age. 

Height  does  not  matter  much,  but  the  candidate 
should  not  be  under  5  feet,  as  he  would  have  diffi- 
culty in  reaching  the  rudder  bar  or  looking  over  the 
cockpit  of  the  aeroplane. 

Weight. — Naturally  the  lighter  the  candidate  the 
better,  but  in  modern  times  with  the  increased  speed 
and  climb  of  aeroplanes  this  does  not  count  so  much 
as  formerly.  Colour,  physique,  attitude,  and  tone 
of  muscles  should  be  noted,  especially  the  abdominal 


muscles,  where  lack  of  tone  would  allow  of  splanchnic 
flooding  and  the  possibility  of  fainting  in  the  air. 
Any  surgical  defect,  no  matter  how  small,  should  be 
recorded  in  the  report,  as  such  may  be  used  and  its 
significance  exaggerated  later  by  a  pilot  who  has 
developed  a  distaste  for  flying. 

The  previous  History  of  Wounds  and  Injuries. — 
These  injuries  have  to  be  carefully  considered — 
especially  injury  to  the  head,  followed  by  prolonged 
unconsciousness  of  recent  origin.  The  author  has 
known  a  few  such  cases,  who  were  all  slow  to  learn, 
made  indifferent  pilots,  were  easily  fatigued,  and  quite 
unfit  for  war  work  in  the  air.  These  cases  all  had 
symptoms  dating  from  their  injury — e.g.,  head- 
aches, easily  fatigued,  emotional  and  subject  to 
vertigo,  and  physical  signs,  such  as  instability  of 
muscle  and  equilibration  sense.  Should  the  head 
injury  not  be  of  recent  origin,  the  candidate  have  no 
symptoms  and  be  able  to  pass  the  tests,  he  should  be 
placed  in  the  special  school  which  has  been  suggested. 
Any  evidence  of  epilepsy,  vertigo,  migraine,  persistent 
headaches,  lack  of  concentration,  and  easily  induced 
fatigue  should  disqualify.  Loss  of  cranial  vault 
need  not  disqualify.  Recently  the  author  passed 
such  a  pilot  as  fit  for  flying.  He  was  able  to  pass 
all  the  tests,  and  had  quite  a  large  piece  missing  from 
the  frontal  region  of  his  skull.  Trunk  injuries  may 
disqualify,  depending  upon  the  amount  of  disable- 
ment and  deformity.  The  author  has  had  four  cases 
of  fracture  of  the  spinal  column  without  injury  to 
the  spinal  cord.  One  has  a  marked  kyphosis  and  is 
not  allowed  to  fly.  Two  have  been  fitted  with  light 
pexuloid  jackets,  which  give  considerable  help.  It 
has  to  be  remembered  that  the  pilot's  seat,  unfor- 
tunately, is  not  built  for  comfort.  Though  he  lacks 
personal  experience  of  cases  of  gunshot  wounds  of 
the  thorax  who  have  returned  to  flying  duties,  the 


author  feels  sure  that  these  should  not  be  rejected 
unless  they  fail  to  pass  the  altitude  tests  as  devised 
by  Lieut.-Col.  Martin  Flack,  R.A.F. 

Disabilities  to  Extremities. — With  regard  to  whether 
disabilities  of  the  extremities  should  cause  rejection 
or  not,  their  significance  depends  on  the  extent 
to  which  they  interfere  with  the  power  to  work  the 
controls  or  use  the  machine-gun.  An  aeroplane 
nacelle  with  the  controls  attached  to  a  dynanometer 
registering  the  minimum  force  required  to  control 
and  fly  the  machine  can  be  used  to  estimate  dis- 
abilities of  the  extremities. 

With  regard  to  the  upper  extremities,  it  is  import- 
ant to  remember  that  most  movements  in  controlling 
the  aeroplane  are  performed  below  the  level  of  the 
shoulder.  Dr.  Head  recently  asked  the  author  to  see 
a  case  of  a  pilot  with  deficient  lower  trapezius  muscle 
action  on  one  side,  so  that  he  could  not  use  the  one 
arm  above  the  level  of  the  shoulder.  It  was  pointed 
out  that  this  pilot  could  quite  well  control  the  aero- 
plane, but  would  be  prevented  from  freeing  a  jamb 
in  a  gun  mounted  on  the  upper  planes.  It  is  much 
more  important  that  the  candidate  should  have 
both  arms  intact  than  both  legs.  Quite  a  few  with 
one  leg  have  still  been  able  to  fly,  and  should  the 
amputation  be  below  the  knee  an  artificial  lower  leg 
and  foot  will  act  quite  well  on  the  rudder  bar. 
Should  the  amputation  be  above  the  knee  the 
artificial  leg  is  dispensed  with  in  flying  and  the 
normal  foot  is  strapped  to  the  rudder  bar,  the 
latter  being  pressed  forward  or  drawn  backward 
in  the  aeroplane's  control  by  the  sound  leg. 

Those  with  orthopaedic  disabilities,  such  as  con- 
tractures, partial  loss  of  power  or  limited  movements 
in  certain  joints,  should  be  tried  in  the  examining 
nacelle.  Those  with  limitation  of  movement  in 
the  ankle  joint  should  be  passed  for  employment  in 


seaplanes  and  other  types  requiring  less  delicate 
control  than  fast  single-seaters.  The  author  has 
known  a  pupil  with  congenital  dislocation  of  one 
hip  who  had  no  difficulty  in  learning  to  fly. 

Old  infantile  paralysis  cases  should  be  rejected, 
owing  to  the  danger  of  trophic  lesions  being  produced 
by  the  cold  of  altitudes.  Candidates  suffering  from 
venereal  disease  must  be  temporarily  rejected.  To 
fly  well  one  must  be  temperamentally  as  well  as 
physically  fit  ;  and  in  venereal  disease,  with  all  its 
attendant  worries,  full  attention  and  concentration 
on  flying,  so  important  in  the  tuition  stages,  cannot 
be  given. 

(2)  The  Medical  Examination 

Before  proceeding  with  this  examination  a  careful 
record  is  made  of  the  candidate's  (a)  previous  occupa- 
tion, habits,  and  mode  of  life  ;  (b)  previous  health  ; 
and  (c)  famih^  history. 

{a)  Previous  Occwpation,  Habits,  and  Mode  of 
Life. — As  a  general  rule  those  whose  previous  occupa- 
tions have  been  of  an  outdoor  nature  and  those  who 
have  been  accustomed  to  playing  outdoor  games 
make  the  better  aviators,  although,  as  in  most  things, 
the  exception  to  the  rule  is  occasionally  to  be  found 
in  the  thoughtful,  quiet,  student  type  who  rarely 
plays  any  games  yet  surprises  everyone  by  his 
rapidity  in  learning  to  fly  and  in  developing  light 
hands  ;  and  conversely  we  meet  the  type  with  fine 
physique,  splendid  courage,  and  in  glowing  health, 
who  learns  to  fly  with  difficulty  and  develops  hands 
like  hams  as  far  as  piloting  the  aeroplane  'is  con- 
cerned. It  should  be  remembered  that  all  aviation 
pupils  are  made  to  undergo  physical  training,  and 
are  given  opportunities  to  indulge  in  various  outdoor 
sports  at  most  flying  schools.  Thus  many  weedy 
and  flabby  individuals  are  soon  licked  into  shape. 


An  inquiry  is  made  into  the  candidate's  habits, 
especially  in  relation  to  tobacco  and  alcohol,  although 
very  little  real  knowledge  is  gained  in  the  examining 
room.  Most  flying  men  smoke  a  great  deal  and 
very  few  are  strict  teetotalers.  Excess  in  smoking 
certainly  leads  to  palpitation,  shortness  of  breath, 
and  in  some  cases  double  vision,  and  these  dangers 
should  be  explained  to  candidates.  Very  few  confess 
to  excess  in  smoking,  and  one  records  with  a  hidden 
smile  the  candidate's  statement  that  he  smokes  five 
cigarettes  a  day,  whilst  the  sunburnt  condition  of 
the  middle  and  index  finger  of  his  right  hand  bears 
silent  testimony  to  a  much  greater  daily  expenditure 
in  tobacco.  Although  the  author  himself  is  not 
a  teetotaler,  he  firmly  believes  that  excess  in  alcohol 
will  ultimately  spoil  the  aviator.  Among  pupils  at 
a  flying  school  alcohol  should  be  strictly  forbidden 
and  candidates  should  be  w^arned  of  its  danger. 
An  aviator  may  fly  under  the  influence  of  alcohol 
and  yet  by  instinct  perform  remarkable  aerial 
stunts.  And  in  one  case  which  was  observed  the 
passenger  was  sick  over  the  side  of  the  machine, 
while  the  pilot,  who  was  under  the  influence  of  drink, 
was  not  affected,  though  the  mere  fact  of  his  attempt- 
ing such  evolutions  on  an  old  and  unsuitable  type  of 
machine  showed  that  his  judgment  was  below  par. 
Fortunately,  nothing  worse  happened.  Tlie  author 
knows  of  another  accomplished  aviator  who  after  a 
few  drinks  at  a  friendly  aerodrome  did  a  series  of 
stunts  and  then  made  off  home,  a  distance  of  thirty 
miles.  He  felt  content  but  sleepy,  made  up  his 
mind  to  do  no  more  stunts  in  the  air,  and  remem- 
bered coming  down  to  land  in  his  own  aerodrome. 
Later  he  woke  up  in  the  sick  bay  with  a  doctor 
stitching  a  scalp  wound.  Although  he  made  up 
his  mind  to  do  no  more  stunts,  onlookers  saw  him 
loop  and  roll  the  machine  a  number  of  times  when 


coming  down  to  land.  There  seems  little  doubt 
that  the  action  of  alcohol  is  accentuated  in  the  air. 

(b)  Previous  Health. — A  great  deal  of  help  can  be 
given  from  a  careful  inquiry  into  the  candidate's 
previous  health.  Recent  temporary  illnesses  such 
as  influenza  and  tonsilitis  may  hinder  a  candidate 
from  passing  the  tests,  yet  his  rejection  should 
only  be  temporary  and  a  re-examination  should 
be  carried  out  later.  A  history  of  untreated  or  im- 
perfectly treated  syphilis  should  be  a  cause  for  rejec- 
tion. A  history  of  malaria  with  recent  attacks 
should  be  a  cause  for  rejection.  In  the  author's 
experience  malarial  cases  rarely  do  well  in  aviation, 
and  he  has  had  to  invalid  out  quite  a  considerable 
number.  The  cold  experienced  in  flying  undoubtedly 
precipitates  malarial  attacks.  If  malarial  cases  are 
allowed  to  fly  at  all  they  should  be  made  to  do  so 
in  warm  climates.  A  history  of  epilepsy  or  petit 
mal  should  disqualify  a  candidate.  Elsewhere  the 
author  has  recorded  the  case  of  a  pupil  who  was 
slow  to  learn  and  was  on  the  point  of  being  turned 
down  on  that  account  alone.  He  was  given  another 
chance  under  another  instructor,  who  reported  fairly 
satisfactory  progress,  but  one  day  the  pupil  in  one 
of  his  early  solo  flights  failed  to  flatten  out,  the 
aeroplane  hit  the  ground  at  its  gliding  angle,  and 
he  was  thrown  clear  of  the  crash  a  distance  of  66  feet 
and  found  quite  unhurt,  although  a  little  dazed  and 
mentally  slow.  A  few  days  later  in  the  mess  this 
pupil  was  seized  with  a  typical  epileptic  seizure, 
which  was  repeated  the  same  night  and  the  following 
day.  A  confession  was  then  forthcoming  that  he 
had  suffered  from  epilepsy  for  the  previous  five 
years  and  that  he  had  taken  bromides  regularly. 
An  epileptic  seizure  in  the  air  was  undoubtedly  the 
cause  of  the  crash. 

Candidates  with  a  history  of  neurasthenia,  nervous 


breakdown,  or  mental  depression,  rarely  do  well  in 
aviation.  Similarly  those  with  a  history  of  shell 
shock  soon  develop  some  form  of  aero-neurosis. 
Such  histories  should  be  estimated  from  the  stand- 
point of  date,  duration,  original  severity,  and  the 
lapse  of  time  with  freedom  from  symptoms.  Having 
made  careful  inquiry  into  the  value  of  a  history 
of  sea-sickness  and  train-sickness  the  author  would 
not  reject  a  candidate  on  such  grounds  unless  for 
balloon  work.  Cases  of  real  air  sickness — that  is, 
sickness  due  to  the  rolling  and  pitching  of  the  aero- 
plane— are  comparatively  rare.  The  actual  vomiting 
usually  occurs  not  during  the  flight,  but  immediately 
after  the  landing.  Should  a  pupil  be  unduly  liable 
to  air-sickness,  this  tendency  is  usually  discovered 
quite  early  in  his  training  whilst  under  dual  control 

A  history  of  recent  tuberculosis  of  the  lungs  should 
cause  rejection  at  once.  The  author  knew  one  pupil 
who  escaped  the  usual  entrance  medical  examination 
and  who  had  active  pulmonary  tuberculosis.  The 
cyanosis  and  respiratory  distress  he  showed  in  his 
trial  flight  were  really  alarming.  He  was  taken 
aside  and  treated  to  a  good  heart-to-heart  talk. 
He  confessed  to  his  disease,  and  said  he  knew  he  could 
not  get  into  the  Army,  but  he  was  keen  on  flying 
and,  in  his  own  words,  "  did  not  care  a  damn  how 
he  finished  up."  Examination  revealed  extensive 
and  advanced  tuberculosis  of  the  lungs.  Finally  he 
was  sent  to  the  south  of  France.  A  history  of 
asthma,  chronic  bronchitis,  or  pleurisy  would  cause 

(c)  Family  History. — The  family  history,  espe- 
cially with  regard  to  diseases  of  the  nervous  system, 
may  shed  some  light  on  the  type  of  soil  with  which 
we  have  to  deal,  especially  in  relation  to  the  strain 
of  war  flying. 


The   Renal,  Digestive,   Circulatory,  Respiratory,  and 
Nervous  Systems 
In    the    medical    examination    these    systems    are 

(a)  Renal. — The  urine  is  examined  for  albumen 
and  sugar  ;    if  present  the  candidate  is  rejected. 

(b)  Digestive. — In  examining  the  digestive  system, 
note  is  taken  of  the  tone  of  the  abdominal  muscles. 
If  the  tone  is  poor  and  there  is  some  dilatation  of 
the  stomach — danger  signals  that  splanchnic  flood- 
ing and  fainting  in  the  air  may  occur — these  cases 
are  sent  back  for  physical  training,  and  if  passed 
for  flying  duties  should  be  advised  to  wear  an 
abdominal  belt. 

(c)  Circulatory. — If  any  organic  disease  of  the 
heart  is  found  the  candidate  is  rejected.  Equally 
important  is  any  evidence  of  instability  of  the  vaso- 
motor system.  Raynaud's  disease  would  disqualify. 
Candidates  showing  coldness  of  the  extremities,  with 
signs  of  defective  peripheral  circulation,  and  a 
history  of  easily  induced  chilblains,  should  not  be 
allowed  to  fly  at  great  heights  but  rather  graded 
for  low-flying  duties.  Among  some  aviators  who 
break  down  and  exhibit  some  type  of  aero-neurosis 
it  is  found  that  there  are  signs  of  vaso-motor  in- 
stability— e.g.^  the  radial  pulse  is  not  well  sustained 
with  the  arm  overhead,  there  is  a  large  pulse  pressure 
on  examination  with  the  sphygmomanometer,  and 
there  are  signs  of  defective  peripheral  circulation 
in  the  extremities.  Candidates  showing  such  signs 
do  not  last  long  as  aviators.  Further  investigation 
is  required  in  such  cases.  The  author  would  not 
reject  them  altogether,  but  rather  place  them  in  the 
special  flying  school.  Many  of  these  cases  may  be 
due  to  recent  temporary  illness,  and,  again,  many  can 
be  improved  by  physical  training.  Personally  the 
author  does  not  attach  much  importance  to  the  pulse- 


rate.  Of  a  large  number  of  pupils  whose  pulse-rate 
he  examined  before  and  after  their  trial  flights  the 
majority  showed  a  rate  varying  from  90  to  120 
before  the  flight  and  with  an  increase  of  10  to  20 
beats  after  landing.  It  has  been  said  that  a  slow 
pulse  is  a  good  sign,  yet  in  a  group  of  fifteen  pupils 
the  one  who  showed  a  slow  pulse-rate,  80  before  the 
flight  and  86  on  landing,  was  the  only  one  of  that 
group  to  give  up  flying  after  his  fourth  solo.  He 
developed  all  the  signs  of  pupil's  aero-nevu'osis. 

(d)  Respiratory  System. — Any  evidences  of  active 
tuberculosis,  emphysema,  bronchitis,  or  pleurisy 
disqualify  for  air  work.  In  war-time  an  aviator 
may  have  to  fly  at  any  height  up  to  about  22,000 
feet ;  at  this  altitude  the  available  oxygen  is  reduced 
by  one-half,  and  consequently  the  respiratory  rate 
is  increased.  Many  aviators  feel  quite  imdisturbed 
at  this  height,  some  feel  respiratory  distress,  fatigue, 
headache,  faintness,  epistaxis  and  blurring  of  vision, 
and  have  to  descend,  whilst  some  actually  faint 
in  the  air.  The  problem  why  some  are  affected 
and  some  are  not  at  great  altitudes  has  been  in- 
vestigated by  Lt.-Col.  Flack.  His  work  is  of  the 
greatest  importance  and  its  value  cannot  be  over- 
estimated with  regard  to  safeguarding  our  airmen. 
Much  of  Lt.-Col.  Flack's  work  cannot  be  referred  to 
now,  but  mention  can  be  made  of  one  of  his  tests, 
namely,  the  breath-holding  test.  In  this  test  the 
candidate,  seated,  is  told  to  expire  once  as  fully  as 
possible,  then  to  inspire  fully  and  hold  his  breath 
as  long  as  possible.  He  is  told  to  imagine  that  he  is 
swimming  under  water  and  to  hold  on  as  long  as 
he  would  do  there.  A  clip  is  placed  on  the  nose. 
Most  good  pilots  are  able  to  hold  the  breath  for  60 
seconds  or  more — 45  seconds  is  the  minimum  for 
the  test.  During  the  breath-holding  there  is  a  deple- 
tion  of   the   alveolar   oxygen   and  the   candidate   is 


submitted  to  a  gradually  rarefying  atmosphere,  as 
in  ascending  to  a  high  altitude.  This  test  has  been 
confirmed  to  be  of  practical  value  by  other  more 
accurate  tests  in  which  the  accumulation  of  COg 
was  eliminated,  and,  moreover,  it  has  been  found 
that  pilots  who  suffer  at  altitudes  cannot  hold  the 
breath  so  long  as  those  who  are  unaffected.  In  the 
absence  of  organic  disej'se  it  is  difficult  to  account 
for  this  disability,  and  various  theories  have  been 
suggested,  such  as  a  low  vital  capacity  or  an  abnormal 
rate  of  oxygen  usage,  or  an  undue  reaction  to  dim- 
inished oxygen.  As  some  fail  in  the  test  through 
lack  of  resolution,  it  is  important  to  ask  the  candi- 
date his  reason  for  giving  up.  The  "  oxygen  want," 
cases  may  reply,  "  I  felt  dizzy,"  "  My  head  began 
to  swim,"  "  Things  got  blurred  "  ;  whilst  the 
normal  cases  usually  say,  "  I  wanted  air,"  "  I  just 
had  to  give  in,"  "  I  felt  like  bvu'sting."  It  is  useful 
also  to  measure  and  record  the  candidates'  vital 
capacity.  The  candidate  should  show  3,000  c.c. 
or  more. 

(e)  Nervous  System. — Any  organic  disease  of  brain 
or  spinal  cord  disqualifies  a  candidate.  The  men- 
tality and  temperament  have  to  be  studied  as  care- 
fully as  possible.  Knee-jerks  are  recorded.  An 
exaggerated  knee-jerk  may  indicate  an  unstable 
nervous  system.  The  candidate  is  tested  for  tremor 
by  making  him  stand  with  the  eyes  shut,  tongue  out, 
arms  extended,  and  fingers  slightly  flexed  and  spread 
apart.  An  inquiry  is  made  into  the  usual  amount 
of  sleep  obtained,  and  whether  disturbed  or  not. 
Any  signs  of  restlessness  are  noted,  such  as  fidgety 
movements  of  hands,  feet,  or  face,  or  biting  the 
nails.  These  would  rather  point  to  an  unstable 
nervous  system.  Yet  the  author  has  in  mind  one 
aviator,  recognised  as  one  of  the  very  best  instructors 
in    our   service,    who   exhibits,   when    not   flying,    all 


forms  of  restlessness,  so  marked  that  it  amounts  to 
a  destruetive  habit.  Unconsciously  he  will  destroy 
many  articles  within  his  reach  ;  at  night  he  can 
often  be  heard  talking  away  in  his  sleep  for  quite 
long  periods. 

(3)  Special  Sense  Examination 

(A)  Vision. — The  author  has  no  doubt  in  his 
own  mind  that  the  aviator  should  have  unaided 
normal  vision  in  both  eyes  and  in  each  eye  separately, 
and  also  normal  colour  vision.  Such  is  required  of  an 
executive  officer  in  the  Royal  Navy,  and  such  should 
be  the  standard  for  air  work.  The  medical  aviation 
authorities  of  the  French  Army  and  of  the  American 
Navy  insist  on  tliis.  He  knows  perfectly  well  that 
there  are  quite  a  number  of  aviators  with  defective 
vision  who  fly  well,  yet  he  knows  also  of  many  who 
have  come  to  grief.  The  pupil  with  defective  vision 
who  attempts  to  learn  flying  will  probably  crash. 
He  would  qualify  this  by  saying  that  should  such  a 
pupil  have  been  an  observer  for  some  time  he  will 
probably  learn  to  fly  quite  well,  his  visual  judgment 
having  been  adapted  by  his  previous  air  experience. 
An  aviator  with  defective  vision  is  undoubtedly  at  a 
disadvantage  in  an  aerial  fight  or  in  reconnaissance 

The  autlior  feels  sure  he  has  saved  some  pupils 
from  disaster  by  advising  them  to  give  up  flying  on 
account  of  their  eyesight.  Every  now  and  then, 
in  aerodrome  life,  one  runs  across  incidents  that 
forcibly  demonstrate  the  value  of  good  vision  to  the 
pilot.  Last  summer  a  pupil  with  defective  vision, 
but  corrected  by  glasses,  was  making  bad  landings. 
He  w^as  on  the  point  of  being  turned  down,  but  was 
allowed  another  chance.  He  made  three  attempts 
to  land — in  the  first  two  he  flattened  out  too  soon 
and  went  up  again,   and  on  the  third  attempt  he 


made  a  good  landing.  Yet  that  same  evening  he 
met  his  death  in  a  crash.  From  the  inquiry  no  doubt 
remains  that  his  glasses  got  displaced  by  his  safety 
helmet,  and  his  uncorrected  defective  vision  was 
insufficient  to  save  him. 

Later  to  the  same  school  came  two  pupils,  each  with 
defective  vision,  one  corrected  and  the  other  not, 
yet  both  learned  to  fly  without  trouble  and  became 
good  pilots,  but  each  had  over  100  hours  to  his  credit 
as  an  aerial  observer. 

In  view  of  the  question  of  man-power  in  the 
supply  of  candidates  for  the  Air  Service,  the  standard 
of  vision  may  have  to  be  lowered,  although  personally 
the  author  is  strongly  against  this.  At  least  it 
should  be  possible  to  have  vision  standards  graded 
for  the  various  flying  duties.  Candidates  should  be 
examined  for  concealed  hypermetropia,  whicli  has 
been  found  in  some  cases  to  be  a  cause  of  making 
bad  landings.  Should  a  candidate  with  each  eye 
read  6/9  with  a  +  2  lens  he  is  rejected.  Similarly, 
heterophoria,  or  concealed  squint,  has  been  found 
to  be  a  cause  of  making  bad  landings.  Such  cases  are 
better  tested  and  watched  by  the  aerodrome  doctor. 
The  test  applied  is  the  red  and  green  light  test. 

Pilots  and  observers  should  have  perfect  colour 
vision.  The  importance  of  this  is  seen  in  picking 
out  the  colour  or  markings  of  hostile  machines,  in 
recognising  signal  lights,  and  in  judging  the  nature 
of  landing  grounds. 

Testing  for  night  blindness  is  only  of  importance 
in  grading  pilots  for  night  bombing.  It  must  be 
remembered  that  there  may  be  a  certain  amount 
of  adaptation  to  light  perception,  and,  again,  that 
the  ideal  conditions  for  night  flying  are  bright 
moonlight  and  no  clouds.  Under  these  conditions 
it  is  almost  impossible  to  spot  an  aeroplane  from 
tlie  ground.     Thus  the  pilot  can  see  well  but  not  be 


seen.  Night  bliadness  is  tested  by  reading  the 
ordinary  test-type  under  gradual  increase  or  decrease 
of  illumination.  It  is  hardly  necessary  to  test  for 
stereoscopic  vision. 

(B)  Aural. — This  includes  examination  of  the 
throat,  nose,  and  ear.  The  previous  history  is  noted 
with  regard  to  pyorrhoea,  recurring  sore  throat, 
earache,  deafness,  or  discharge  from  the  ears.  The 
teeth  and  gums  are  examined,  as  it  is  essential  that 
the  pupils  should  commence  flying  dentally  clean. 
Most  aviators  fly  with  the  mouth  slightly  open  and 
any  minor  degree  of  oral  sepsis  flares  up  owing  to 
the  cold  or  rush  of  air  experienced  in  flying.  In 
one  pupil  with  pyorrhoea  the  author  saw  a  very 
severe  gingivitis  induced  through  flying.  In  pro- 
peller types  of  aeroplanes — i.e.,  with  the  engine 
behind — there  is  little  protection  from  the  rush  of 
air.     Septic  tonsils  should  be  enucleated. 

The  nose  is  examined  to  estimate  the  amount  of 
clear  airway.  The  Italians  lay  stress  on  this  exam- 
ination and  even  take  tracings  of  the  degree  of  nasal 
stenosis  by  means  a  nasal  catheter,  plug,  and  record- 
ing manometer.  Many  pilots  with  septal  deviation 
and  enlarged  turbinates  have  flown  without  dis- 
comfort, whilst  others  have  been  returned  suffering 
from  headaches  induced  in  the  air.  Some  have 
had  submucous  resection  performed  in  the  hospital 
lately  and  have  been  returned  to  flying  duties. 
Reports  from  them  later  will  help  to  settle  the 
relationship  between  nasal  obstruction  and  head- 
aches induced  by  flying.  Further  observation  on  a 
series  of  cases  is  required.  Cases  with  adenoids, 
and  nasal  polypi  or  infective  sinuses,  are  temporarily 
rejected  until  treatment  has  been  carried  out. 

Hearing  must  be  normal  and  each  ear  is  tested 
separately  by  forced  whisper  at  a  distance  of  20  feet. 
The  author  uses  terms  employed  in  aviation  such  as 


"  contact  "  and  "  switch  off."  The  aviator's  hearing 
becomes  tuned  to  the  sound  of  his  engine  and  any 
misfiring  is  at  once  detected  and  action  taken  accord- 
ingly. Defective  hearing  in  the  pilot  or  air  mechanic 
may  lead  to  serious  injury  or  even  death  to  the  latter 
in  starting  up  the  engine  preparatory  to  a  flight.  In 
this  act  the  mechanic  swings  the  propeller  and  should 
the  aviator,  through  defective  hearing,  fail  to  catch  the 
words  "  contact  "  or  "  switch  off,"  as  the  case  may  be, 
the  engine  may  unexpectedly  start  and  the  propeller  in- 
jure or  kill  the  mechanic.  Chronic  suppurative  disease 
of  the  middle  ear  is  a  cause  for  rejection.  Similarly 
it  is  well  to  reject  any  cases  showing  perforation  of 
the  tympanic  membrane  or  cicatrices.  These  cases 
would  probably  suffer  from  pain  in  the  ears  induced 
by  the  incessant  noise  of  the  engine  and  by  pressure 
effects  from  changing  height  rapidly.  There  is  also 
the  possibility  of  permanent  deafness  ensuing  later. 

(C)  Equilibration  and  Muscle  Sense. — It  has  been 
assumed  that  a  sound  equilibration  and  muscle  sense 
is  essential  in  flying,  so  that  the  aviator  would  be 
conscious  of  his  position  in  space,  realise  at  once 
any  deviations  therefrom,  and  correct  these  quickly. 
But  in  fog  it  has  been  found  almost  impossible  to 
detect  any  deviation  during  a  flight.  Time  and 
again  aviators  coming  out  of  dark  clouds  or  fog  have 
found  themselves  flying  one  wing  down,  and  it 
has  been  recorded  that  some  have  flown  upside 
down  without  knowing  it.  Thus,  it  is  obvious  that 
most  of  the  impressions  which  control  balance  in 
flying  come  through  the  eyes. 

To  investigate  this  the  author  did  the  following 
experiment,  having  Flight-Commander  McMinnies, 
R.X.,  as  pilot,  the  author's  sense  of  balance  and 
vestibular  reactions  having  previously  been  found 
normal  by  Mr.  G.  J.  Jenkins  : — 

Blindfolded  and  with  ears  plugged  he  sat  in  the 



stern  seat  of  an  aeroplane  in  telephonic  communica- 
tion with  the  pilot  in  front.  The  latter  had  to 
perform  certain  evolutions  in  the  air,  and  these 
and  his  own  position  in  space  the  author  had  to 
describe  to  the  pilot  during  the  flight.  At  first  he 
was  able  to  describe  the  flight  fairly  accurately — 
the  climbing,  flying  with  right  wing  down,  the  first 
spiral  downwards  to  the  right  ;  after  that  he  was 
"  all  at  sea,"  and  thought  the  machine  was  climbing 
up  and  up  continuously,  whilst  in  reality  it  was 
spiraling  down  to  the  left.  He  was  able  to  record 
the  latter  part  of  the  descent  to  land. 

He  thinks  this  experiment  goes  far  to  prove  that 
the  aviator  is  for  the  most  part  dependent  on  im- 
pressions conveyed  through  the  eyes  for  his  sense 
of  balance  during  a  flight.  Nevertheless,  although 
further  investigation  is  required  in  this  direction, 
it  is  his  view  that  every  candidate's  equilibration, 
muscle  sense,  and  vestibular  reactions  should  be 

The  following  are  the  tests  generally  employed  : — 

(a)  Self-balancing  at  rest  and  in  motion.  The 
candidate  with  his  eyes  shut  and  hands  on  his  hips 
is  asked  to  stand  on  one  leg.  He  should  do  this 
for  15  seconds  on  each  leg.  He  then  walks  in  a 
straight  line  heel  to  toe,  but  with  eyes  open,  and  at 
a  given  signal  he  has  to  pivot  round  and  walk  in  the 
opposite  direction  without  losing  balance. 

{b)  The  muscle  sense  can  be  tested  in  two  ways — 
firstly,  by  asking  the  candidate  to  appreciate  differ- 
ence in  weight  between  articles  of  a  similar  size  ; 
and  secondly,  by  making  him  raise  a  cigar-box  lid 
on  which  is  balanced  a  tuning-fork,  five  inches  in 
height  and  with  a  small  foot-piece,  from  a  table  to 
the  level  of  the  shoulder  and  down  again.  Those 
with  a  good  muscle  sense  can  do  this  without  up- 
setting the  tuning-fork.     ]Many  can  raise  the  appar- 


atus  successfully  but  in  lowering  it  fail,  indicating 
carelessness  and  an  impulsive  nature.  It  may  be 
pointed  out  that  the  muscle  sense  is  called  into 
play  quite  a  lot  in  flying — especially  impressions 
from  the  buttocks.  In  running  into  air-pockets 
the  aeroplane  may  be  suddenly  bumped  upwards 
or  downwards  as  a  whole,  or  rocked  in  a  lateral  or 
fore-and-aft  direction.  These  deviations  are  often 
felt  in  the  buttocks,  and  with  a  quick  reaction  time 
in  the  pilot  the  aeroplane  is  soon  on  a  level  keel. 
In  fact,  an  accomplished  aviator  seems  to  anticipate 
bumps.  These  tests  a  and  h  were  devised  by  Lieut. - 
Col.  A.  H.  Cheatle,  R.A.F. 

(c)  The  vestibular  reaction  is  tested  either  by 
means  of  the  rotation  test  or  the  caloric  test. 

In  the  rotation  test  the  candidate  sits  in  a  revolving 
chair  fitted  with  arm-rests,  foot-rest,  and  a  head-rest 
inclined  forward  at  30°.  He  is  told  to  close  his  eyes 
and  the  chair  is  then  rotated  evenly  from  right  to 
left  six  times,  each  rotation  lasting  two  seconds. 
The  eyes  are  then  opened  at  a  given  signal  and  the 
candidate  looks  to  his  left  at  the  examiner's  right 
forefinger.  The  nystagmus  so  induced  is  noted 
with  regard  to  its  duration,  degree,  and  type.  The 
test  is  then  repeated  in  the  opposite  direction.  The 
duration  of  the  nystagmus  in  normal  cases  varies 
from  12  to  25  seconds,  anything  over  25  indicates 
an  easily  stimulated  vestibular  mechanism.  With 
regard  to  the  degi'ce  of  nystagmus,  the  majority 
show  fine  rapid  oscillations,  but  some  show  large  and 
slow  oscillations,  whilst  some  exhibit  a  mixed  form. 
The  type  of  nystagmus  is  almost  invariably  in  a 
lateral  direction,  but  the  author  has  seen  vertical 
nystagmus  with  a  curious  rotation  of  the  eyeball. 
Mr.  Jenkins  has  pointed  out  that  in  those  with  a 
liighly  trained  vestibular  mechanism,  like  the  acrobat, 
the    nystagmus    induced    is    of    short    duration    or 


absent.  At  present  it  is  difficult  to  interpret  tlie 
readings,  and  investigation  is  required  to  find  whether 
the  individual  with  a  highly  trained  vestibular 
mechanism  or  the  opposite  makes  the  better  aviator. 

It  is  essential  to  have  a  rotation  chair  worked 
electrically,  as  an  uneven  rate  of  rotation  alters  the 
findings  considerably.  Having  treated  by  rotation 
over  a  hundred  pupils  and  skilled  pilots  the  author 
cannot  come  to  any  definite  conclusion  with  regard 
to  the  value  of  duration  or  degree  of  nystagmus, 
except  that  perhaps,  if  any,  the  most  experienced 
give  a  shorter  duration.  Curiously  enough  the  one 
pupil  who  exhibited  slow  vertical  nystagmus  with 
some  rotation  soon  developed  aero-neurosis  and 
gave  up  flying. 

In  the  caloric  test  the  nystagmus  is  induced  by  a 
gentle  continuous  flow  of  water  at  70°  Fahr.  into  one 
ear.  The  period  of  induction  and  the  duration  of 
nystagmus  are  recorded. 

It  has  been  suggested  that  the  sense  of  ijrojection 
should  be  tested.  In  this  test  the  candidate  looks 
fixedly  at  the  bull's-eye  of  an  indoor-range  target 
until  he  locates  its  position  in  space.  He  then 
closes  his  eyes  and  attempts  to  place  the  forefinger 
of  his  right  hand  on  the  bull's-eye.  The  readings 
are  noted  down  as  bull,  inner,  outer,  or  miss — ^good 
pilots  are  supposed  to  score  bulls  or  inners.  The 
author  has  tried  this  test  with  a  number  of  aviators, 
but  so  far  cannot  estimate  its  full  value.  He  has 
made  an  attempt  to  test  the  aviator's  sense  of 
direction.  In  this  test  the  instructor  takes  the 
pupil  for  a  flight,  spirals  him  twice,  and  then  through 
the  telephone  asks  him  to  point  out  a  certain  land- 
mark on  the  aerodrome — e.g.,  a  particular  hangar. 
By  means  of  a  stop-watch  the  instructor  notes  the 
time  taken  to  accurately  point  out  the  object.  With 
the    few    tests    that    Flight-Commander    McMinnies 


carried  out  at  his  request  the  time  taken  by  the  pupil 
was  about  4  seconds. 

(D)  The  Psycho- Motive  Reactions. — It  is  important 
that  the  aviator  should  possess  normal  reaction  times 
with  regard  to  vision,  hearing,  and  touch.  All  parts 
of  the  reflex  arcs  involved  must  be  intact.  These 
reaction-times  are  tested  by  means  of  the  D'Arsonval 
chronometer,  which  determines  accurately  at  what 
fraction  of  a  second,  after  having  received  a  visual, 
auditory,  or  tactile  stimulus,  the  candidate  under 
examination  reacts.  By  means  of  this  instrument 
Dr.  Camus,  Dr.  Nepper,  and  Dr.  Binet  have  in- 
vestigated the  reaction  times  among  aviators. 
In  early  1917  the  author  had  the  pleasure  of  visiting 
our  French  colleagues  at  the  Grand  Palais  in  Paris, 
and  was  given  every  opportunity  to  witness  and 
study  their  tests,  with  the  value  of  which  he  was 
considerably  impressed.  The  D'Arsonval  chrono- 
meter is  worked  electrically,  and  has  a  clockwork 
movement  turning  a  pointer  on  a  dial,  divided  into 
100  parts,  at  a  speed  of  one  revolution  a  second. 
There  are  two  press  button  switches,  one  held  by  the 
examiner  and  one  by  the  candidate. 

To  measure  the  visual  reaction-time  the  examiner 
starts  the  pointer  revolving  by  pressing  his  thumb- 
switch,  and  once  the  candidate  perceives  the  pointer 
moving  he  stops  it  by  pressing  his  thumb-switch. 
The  time  taken  is  noted  on  the  dial.  The  normal 
vision  reaction  time  is  19/100  of  a  second,  but  in 
unsuitable  candidates  may  be  slowed  down  from 
22/100  to  48/100  of  a  second.  The  visual  reflex 
consists  of  the  impressions  carried  through  the  eyes 
to  the  brain  and  from  there  down  to  the  muscles 
controlling  hands  and  feet.  For  example,  the  aviator 
perceives  one  wing  tilted  up  to  the  right,  and  this 
impression  is  carried  through  his  eyes  to  the  brain, 
there  recorded,  and  a  decision  made,  which  is  trans- 


mitted  to  the  hands,  so  that  the  control  lever  is 
pushed  over  to  the  right  and  the  aeroplane  is  made 
to  assume  an  even  keel  again.  Or,  as  in  landing, 
when  the  impression  that  he  is  near  enough  to  the 
ground  is  transmitted  through  the  eyes  to  the  brain 
and  down  to  his  hands,  he  pulls  back  the  control  lever 
at  the  correct  moment,  and  the  aeroplane  flattens 
out  just  as  the  ground  is  reached.  Should  the  visual 
reaction-time  be  delayed  in  landing,  a  crash  is  likely 
to   ensue. 

The  auditory  reaction-time  is  tested  by  the 
examiner  tapping  the  table  with  his  thumb-switch, 
which  again  causes  the  pointer  to  move,  whilst  the 
candidate  facing  away  from  the  instrument  stops 
the  pointer  with  his  thumb-switch  on  hearing  the 
tap.  The  auditory  reaction-time  usually  takes  14/100 
of  a  second,  but  may  be  delayed  from  17/100  to 
33/100.  In  the  auditory  reflex  the  impressions  are 
carried  through  the  car  to  the  brain  and  down  to  the 
muscles  of  control.  For  example,  in  flying  the  pilot 
may  hear  his  engine  miss-fire,  and  the  decision  to 
find  a  good  landing-place  is  at  once  transmitted  to 
the  muscles  controlling  eyes,  feet,  and  hands. 

The  tactile  reaction-time  is  recorded  in  a  similar 
way,  the  examiner  tapping  the  candidate  on  the 
head  or  hand,  and  the  latter  on  feeling  this  stops 
the  pointer.  The  normal  tactile  reaction-time  is 
14/100  of  a  second,  but  may  be  slowed  from  20/100 
to  39/100.  The  tactile  reflex  consists  of  impressions 
conveyed  from  the  nerve  endings  in  skin  and  muscles 
to  the  brain  and  down  to  the  muscles  of  control. 
For  example,  when  a  pilot  feels  a  "  bump  "  the  sensa- 
tion is  carried  from  the  skin  and  muscles  of  his 
buttocks  to  the  brain,  and  a  decision  is  transmitted 
to  the  muscles  controlling  his  feet  and  hands  to 
correct  the  effects  of  the  bump.  Each  reaction-time 
is  tested  ten  times  and  an  average  taken.  ^  All  these 


reaction-times  are  found  delayed  if  the  candidate  be 
physically  or  temperamentally  unfit,  as  in  disease, 
worry,  cold,  fatigue,  and  after  excesses. 

A  slow  reaction-time,  the  delay  of  a  second  or 
part  of  a  second  in  correcting  an  error  in  the  air 
or  in  landing,  may  mean  all  the  difference  between 
a  crash  and  safety. 

In  1915  the  author  devised  the  following  test,  but 
so  far  has  not  had  the  means  of  carrying  it  out.  The 
idea  was  to  measure  the  candidate's  reaction-time 
in  correcting  "  bumps."  Use  was  to  be  made  of  a 
rocking  fuselage  fitted  with  controls  and  an  electrical 
recording  apparatus.  In  this  the  candidate  was  to 
sit  ready  as  for  flying.  The  examiner  was  to  tilt 
the  fuselage  either  laterally,  or  fore  and  aft,  and  the 
pupil  had  to  correct  this,  and  the  time  taken  was 
to  be  recorded  electrically.  This,  from  the  point  of- 
\4ew  of  practical  aviation,  would  be  another  method 
of  testing  the  candidate's  tactile  reaction-time. 

(E)  The  Emotional  Reactions. — In  this  test,  which 
has  been  elaborated  by  Dr.  Nepper,  the  influence  of 
the  emotions  on  the  respiratory  rhythm,  the  vaso- 
motor control,  and  tremor  is  recorded  graphically. 
It  is  more  a  gi-ading  test  in  determining  the  best 
type  of  aviator  for  aerial  fighting  rather  than  an 
entrance  test  for  aviation  candidates. 

The  aviator  has  round  his  chest  a  pneumograph, 
in  his  left  hand  a  trembler,  and  round  two  fingers 
of  his  right  hand  a  pneumatic  "  doigticr."  All  three 
are  connected  by  rubber  tubes  to  stylets  writing 
on  a  blackened  revolving  cylinder,  and  thus  are 
recorded  the  respiratory  rhythm,  any  tremor  present, 
and  the  peripheral  vasomotor  control.  Behind  the 
candidate  a  revolver  shot  is  fired  or  a  magnesium 
flare  set  off,  and  on  the  smoked  paper  a  record  is 
made  of  any  variations.  In  the  best  type  of  pilot 
with  good  nerves  the  effects  recorded  are  of  short 


duration,  whilst  in  unsuitable  ones  the  respiratory 
rhythm  remains  increased  for  some  time,  there  is 
marked  tremor,  and  peripheral  vaso-motor  con- 
strietion.  The  author  saw  the  graphic  records  of 
some  of  the  best  French  aviators  who  underwent  this 
test.  Much  remains  yet  to  be  done,  and  there  are 
many  problems  awaiting  elucidation  in  the  selection 
of  candidates  for  aviation  duties. 


The  Applied  Physiology  of  Aviation 

By  Lt.-Col.  Flack,  R.A.F. 

*'  If  men   were    meant   to    fly   they  would  have  been 
given  wings.'''' 

But  a  few  years  ago  such  a  remark  as  this  was 
common  enough,  especially  during  the  period  when 
the  brilliant  pioneers  of  flying  were  making  their 
most  fundamental  experiments.  Now,  as  a  result 
of  their  successful  efforts,  man  is  able  to  fly,  and 
indeed  flying  is  a  common  everyday  performance. 
It  is  true  that  man  has  not  developed  wings  but  has 
provided  a  motor  and  wings  as  an  accessory  to 
himself.  Nevertheless  in  flying  he  and  his  machine 
become,  to  all  intents  and  purposes,  a  single  entity. 
Although  flying  has  become  possible,  not  all 
men  can  acquire  the  art  of  flying.  To  do  this, 
certain  physiological  attributes  are  especially  neces- 
sary. In  addition,  if  not  perhaps  even  more  import- 
ant, is  a  psychological  attribute,  namely,  the  flying 
temperament.  It  is  not  proposed,  however,  to  treat 
on  this  in  any  detail  here.  Suffice  it  to  point  out 
that  a  really  successful  aviator  is  still  possessed  of 
the  temperament  characteristic  of  the  pioneers ; 
he  is  endowed  with  absolute  fearlessness,  a  love  of 
adventure  and  sport,  and  a  dogged  determination 
to  overcome  every  difficulty,  no  matter  how  in- 
superable   it    may    appear.     In    these    days    of    war 



also,  the  successful  aviator  possesses  what  may  be 
termed  the  "  fighting  temperament." 

From  a  physiological  point  of  view,  however,  it 
is  obvious  that  since  man  has  added  to  himself 
wings  and  a  motor,  the  most  important  factor  in 
the  art  of  flying  is  the  nervous  control  and  co- 
ordination of  the  reflexes  necessary  for  the  successful 
management  of  these  accessory  parts.  An  insight 
into  the  motor  side  of  these  "  flying  reflexes  "  and 
their  co-ordination  is  easily  afforded  by  getting  into  a 
stationary  machine  and  studying  the  fundamental 
effector  movements  ("  effector  responses  "),  necessary 
to  flying.  These  fundamental  effector  movements 

(1)  With  the  arms  a  fore  and  aft  and  a  side  to 
side   movement. 

(2)  With  the  legs  a  to-and-fro  push  of  the  rudder 

Careful  study  of  these  movements  in  a  stationary 
machine  at  once  brings  home  the  fact  that  these 
"  effector  responses "  are  by  no  means  easy  to 
acquire.  The  combination  of  hand  and  foot  move- 
ment is  by  no  means  familiar  to  the  average  person, 
and  while  attention  is  directed  to  one  movement, 
the  other  movement,  equally  important,  is  for 
the  time  being  neglected.  Thus,  when  the  attention 
is  directed  to  the  hand  movement  the  foot  move- 
ment is  forgotten  for  the  time  being,  and  becomes 
inco-ordinate.  This  is  brought  out  even  more  effect- 
ively if,  instead  of  being  performed  in  a  stationary 
stable  machine,  the  movements  are  tried  in  an 
unstable  apparatus  which  responds  to  each  move- 
ment of  the  joy-stick  and  rudder.  In  these  circum- 
stances it  is  quickly  realised  that  it  is  a  matter  of 
very  great  difficulty  to  maintain  by  appropriate  arm 
and  leg  movements  an  even  keel  while  in  a  state  of 
unstable   equilibrium. 


In  practically  no  other  acquired  accomplishment 
has  man  to  keep  so  many  groups  of  antagonistic 
muscles  in  a  state  of  "  static  "  wakefulness  or  to 
perform  such  a  variety  of  constant  co-ordinated  leg 
and  arm  movements.  It  is  for  this  reason  that  the 
acquiring  of  the  art  of  flying,  even  in  the  apt  pupil, 
is  a  matter  of  hours  and  not  of  minutes.  For  this 
reason  also  the  period  of  training  for  flying  is  rela- 
tively long,  since  it  is  fully  realised  that  a  con- 
siderable period  of  time  is  necessary  before  the 
essential  movements  in  flying  have  developed  into 
subconscious  reflexes. 

From  the  above  considerations  it  is  obvious  that 
the  successful  flier  must  be  one  who  has  power  to 
co-ordinate  his  limb  muscles  with  a  beautiful  degree 
of  refinement.  By  some  people  it  is  held  that  the 
previous  training  of  a  horseman  has  given  him  the 
necessary  qualifications.  It  should  be  borne  in 
mind,  however,  that  although  such  horsemanship 
has  given  him  delicately  co-ordinated  arm  move- 
ments, "  hands,"  the  more  difficult  co-ordinated 
arm  and  leg  movement  necessary  for  flying  has  not 
been  thereby  acquired,  since  the  leg  movements 
of  horsemanship  are  of  a  different  order  to  those 
employed  in  flying.  By  this  it  is  not  intended  to 
infer  that  the  possession  of  a  good  pair  of  hands 
and  of  a  good  sense  of  balance,  acquired  in  the  art 
of  horsemanship,  is  not  a  valuable  accessory  to  the 
acquisition  of  the  art  of  flying. 

Tlie  man  who  has  not  the  power  of  delicately 
co-ordinating  his  arm  and  leg  movements  will  be 
deemed  "  ham-handed,"  "  heavy-footed,"  or  "  never 
able  to  acquire  the  art  of  flying."  It  is  because  of 
the  importance  of  this  delicately  co-ordinated  effector 
response  that  great  importance  is  attached  to  a 
history  of  sport  in  the  selection  of  aviators. 

While  a  history  of  sport  is  of  great  importance, 


even  greater  is  a  history,  if  it  can  be  ascertained,  of 
acquiring  a  proficiency  in  sport  easily.  In  other 
words,  such  a  man  has  ahxady  shown  himself  an 
adept  at  acquiring  rapidly  a  new  series  of  reflex 
acts,  and  other  things  being  equal  youth  has  a  great 
advantage  here. 

We  next  come  to  the  consideration  of  the  sensory 
side  of  these  reflex  arcs.  By  what  afferent  paths 
are  impulses  conveyed  to  the  final  effector  paths. 
Putting  aside  the  question  of  intelligence  by  which 
the  subject  appreciates  the  information  given  him 
by  the  instructor  by  oral,  and  to  a  certain  extent 
by  visual  means,  through  what  mechanisms,  cxtro- 
ceptive  and  proprioceptive,  is  the  art  of  flying 
acquired  ?  Without  danger  of  contradiction,  it  can 
be  confidently  affirmed  that  the  visual  reflex  is  all 
important  to  the  aviator.  It  is  for  this  reason  that 
many  authorities  pay  considerable  attention  to  the 
determination  of  the  time  of  the  experimental  visual 
reflex,  especially  in  the  selection  of  scout  pilots. 

Again,  the  auditory  sense  is  of  considerable  im- 
portance, especially  in  the  detection  of  any  mechanical 
defect  in  the  running  of  the  engine,  and  because  the 
flier  derives  much  information  as  to  the  position  of 
his  machine  by  the  "  singing  "  of  the  wind  through 
the  wires  of  the  machine, 

A  point  of  considerable  difficulty  arises,  however, 
in  connection  with  what  may  be  called  "  sense  of 
balance."  Considerable  divergence  of  opinion  exists 
as  to  the  part  played  by  afferent  impulses  from  the 
eye,  cutaneous  nerve  endings,  "  muscle  sense,"  and 
from  the  vestibular  mechanism. 

In  regard  to  the  last  it  is  frequently  argued  that 
since  the  vestibular  mechanism  especially  is  developed 
in  birds,  it  is  important  that  men  in  whom  the 
mechanism  is  functioning  especially  well  should  be 
selected  for  aviation.     True  as  this  may  appear  at 


first  sight,  tlie  fact  must  not  be  overlooked  that 
regarding  the  man  and  his  machine  as  a  single 
entity,  the  accessory  parts  added  to  man  have,  to 
a  considerable  extent,  their  own  sense  of  balance. 
In  other  words,  it  must  not  be  overlooked  that  most 
modern  machines  are  possessed  of  a  considerable 
degree  of  inherent  stability,  and  on  this  account 
there  is  no  reason  to  suppose  that  machines  cannot 
be  effectively  flown  by  men  in  whom  the  vestibular 
mechanism  is  not  especially  sensitive. 

This  may  well  be  the  case,  since  it  is  known  that 
cutaneous  sensations,  especially  from  the  seat  and 
also  from  the  alteration  in  direction  of  wind  pressure 
on  the  cheeks,  play  with  most  pilots  a  very  important 
part  in  giving  them  an  idea  of  their  projection  in 
space.  Much  information  is  also  derived  from  the 
"  feel  "  of  the  joy-stick  and  the  joint  and  muscle 
sense  brought  into  play  in  its  manipulation. 

The  sense  of  vision,  however,  is  here  also  of  the 
greatest  importance.  As  described  elsewhere,  the 
author  of  this  book  found  that  when  his  eyes  were 
bandaged  and  his  ears  were  plugged,  after  the  first 
few  evolutions  he  had  little  or  no  idea  of  his  position 
in  space,  indeed  he  had  the  impression  that  he 
was  ascending  continuously.  This  his  been  con- 
firmed by  other  observers,  and  it  is  also  a  well-known 
fact  that  an  aviator  after  flying  a  long  time  in  a 
cloud  will  have  but  little  knowledge  of  the  position 
in  which  he  will  emerge  from  that  cloud  with  rela- 
tion to  the  earth. 

A  very  experienced  pilot  tried  an  experiment 
similar  to  the  one  mentioned  above.  He  found 
that  he  could  tell  the  kind  of  evolutions  being 
executed  fairly  well  chiefly  because  of  the  "  feel  " 
of  liis  seat.  When,  however,  he  tried  to  fly  he 
could  not  perform  correctly  even  quite  elementary 
movements.     Thus  in  making  a  turn  he  "  stalled,'* 


but  was  only  aware  of  the  fact  on  account  of  the 
feel  of  the  joy-stick.  Later  he  got  his  nose  right 
down,  but  again  he  only  became  aware  of  this 
because  of  the  feel  of  the  joy-stick. 

To  sum  up,  in  acquiring  the  art  of  flying,  it  is 
necessary  for  the  would-be  flier  to  be  possessed  of — 

(1)  A  good  sense  of  vision  and  hearing,  and  a 
quick  effector  response  to  impulses  thereby  received. 

(2)  A  good  sense  of  balance  in  which  impulses 
derived  from  the  skin,  muscles  and  joints  play  as 
important  a  part  as  do  those  derived  from  the  semi- 
circular canals. 

(3)  A  delicate  co-ordination  of  muscular  move- 
ments, particularly  in  the  interplay  between  the 
antagonistic  muscles  concerned  in  the  various  move- 
ments performed  by  those  muscles. 

Given  the  above  assets,  the  pupil  will  during 
his  stage  of  dual  training  so  perfect  his  effector 
responses  that  after  a  time  his  flying  will  become 
more  or  less  automatic.  If  this  be  not  the  case, 
then  he  will  never  become  an  efficient  pilot,  and 
will  early  develop  fatigue. 

It  is  absolutely  necessary  that  quite  early  in  his 
flying  career  the  subject  should  be  able  to  divert  his 
attention  elsewhere  than  to  the  arm  and  leg  move- 
ments necessary  for  flying.  It  becomes  necessary 
for  the  pilot  to  find  his  way  across  country,  to  read 
maps,  to  practise  photography,  bomb-dropping  and 
gunnery,  during  all  of  which  machines  should  be 
flown  more  or  less  subconsciously.  Finally,  having 
acquired  such  flying  sense,  it  becomes  the  lot  of 
many  pilots  to  practise  almost  subconsciously  diffi- 
cult aerobatics,  while  acquiring  what  may  be  known 
as  the  "  fighting  sense." 

It  must  again  be  emphasised  here  that,  in  the 
acquisition  of  all  these  adjuncts  to  flying,  visual 
acuity  is  all  important. 


It  is  for  this  reason  that  during  the  ground  training 
of  the  flying  officer,  and  also  througiiout  his  career, 
especial  attention  should  be  given  to  those  sports 
which  aid  in  the  acquisition  of  what  may  be  termed 
*'  eye."  Of  especial  value  in  this  connection  is 
fencing.  But  other  sports,  such  as  boxing,  shooting, 
tennis,  and  badminton  are  of  great  service. 

Altliough  '*  eye  "  is  to  a  large  extent  an  inborn 
gift,  it  is  to  be  emphasised  that  it  can  also  be  culti- 
vated to  a  large  extent.  Thus  no  matter  how  good 
be  the  "  eye  "  of  a  first-class  bat,  he  will  not  main- 
tain his  form  except  by  constant  practice.  So  with 
the  "  eye  "  of  the  aviator. 

Besides  playing  a  part  in  the  acquisition  of  "  eye," 
sport  aids  the  acquisition  of  delicate  muscular 
co-ordinated  movement  and  balance.  For  instance, 
it  is  undoubtedly  good  practice  for  any  one  to  set 
himself  such  a  simple  task  as  to  acquire  the  art  of 
bowling  a  good  length  ball.  Thus  a  man  who  can 
hit  a  piece  of  paper  the  size  of  half-a-crown  six  times 
in  six  balls  has  developed  a  delicate  series  of  co- 
ordinated reflexes.  Fencing,  already  mentioned,  is 
of  especial  value  in  acquiring  "  eye  "  balance,  and 
quick  co-ordinated  movement. 

Thus  far  we  have  been  dealing  with  the  acquisi- 
tion of  the  art  of  flying.  It  is  necessary  also  to 
deal  with  the  strain  which  flying  imposes  on  the 
body,  especially  at  high  altitudes.  The  increased 
speed  of  the  machines,  their  heightened  ceiling, 
the  greater  rapidity  with  which  they  climb,  have 
carried  aerial  warfare  to  such  an  altitude  that  the 
aviator  has  to  be  able  to  live  and  work  in  an  atmos- 
])here  where  the  vital  constituent,  oxygen,  is  dimin- 
islied.  Thus  superadded  to  the  nervous  strain 
involved  in  learning  to  fly,  is  the  physical  one, 
which  falls  particularly  upon  the  respiratory  and 
oireuhitory  mcelianisms.     To  understand  tliis  strain. 


it  should  be  explained  that  these  mechanisms  are 
called  upon  to  function  in  an  atmosphere  of  dimin- 
ished oxygen,  where,  if  anything,  an  increased  supply 
is  required  :  there  is  thus  the  tendency  to  the  estab- 
lishment of  a  vicious  circle,  a  demand  for  increased 
oxygen  supply  in  an  atmosphere  in  which  it  is  pro- 
gressively diminishing  as  the  aeroplane  mounts. 
Many  of  the  symptoms  from  which  airmen  are 
liable  to  suffer  are  due  to  the  strain  thrown  upon 
these  bodily  systems.  For  this  reason  the  would-be 
aviator  must  start  out  upon  his  training  with  a 
particularly  sound  constitution,  above  all  his  cir- 
culatory and  respiratory  mechanisms  must  be  perfect, 
and  it  is  on  this  account  that  so  great  care  is  exercised 
in  his  selection  on  admission  to  the  service.  For 
this  reason  also,  the  flying  officer  who  wishes  to  be 
successful  should  keep  himself  trained  and  fit,  he 
should  look  upon  himself  as  being  engaged  in  a 
sport  necessitating  careful  habits  of  life  approximat- 
ing almost  to  those  of  hard  training,  so  that  his 
efficiency  may  not  be  impaired. 

As  an  aviator  climbs,  he  passes  from  the  normal 
barometric  pressure  at  ground  level  to  a  pressure 
wiiich  diminishes  according  to  the  height  attained. 
Thus,  his  body  becomes  directly  exposed  to  an  altera- 
tion in  the  air  pressure,  as  well  as  to  an  atmosphere 
in  which  less  oxygen  is  available  for  the  body  needs. 

The  experience  gained  from  a  study  of  "  mountain 
sickness  "  does  not  help  us  greatly  in  understanding 
this  question,  for  mountain  climbers  attain  their 
heights  at  a  relatively  slow  rate,  and  the  body  has 
an  opportunity  to  adapt  itself  to  its  new  surroundings. 
Such  adaptation  takes  generally  from  seven  to  ten 
days.  But  the  aviator  on  a  high  flying  machine 
may  attain  a  height  of  20,000  feet  in  30  to  40  minutes, 
and  remain  at  that  height  for  but  a  short  time,  at 
the  most  a  few  hours,  a  time  so  short  that  the  body 


has  little  or  no  opportunity  to  adapt  itself  to  its  new 
conditions.  Even  when  one  considers  the  case  of 
an  aviator  flying  regularly  over  a  long  period,  the 
number  of  hours  at  which  he  has  kept  at  a  great 
altitude  are  but  few  compared  to  the  number  he  has 
spent  on  the  ground — say,  for  example,  240  hours 
(10  days)  in  1000  hours  flying,  spread  over  two  years. 

The  information  gained  by  balloonists  as  to  the 
effects  of  altitude  upon  the  bodily  mechanisms  has 
been  more  helpful.  They  have  been  able  to  attain 
great  heights  in  a  relatively  short  space  of  time, 
and  further,  have  been  able  to  make  observations 
as  to  the  behaviour  of  the  breathing,  heart,  etc., 
under  these  conditions.  Tiiis  knowledge  has  been 
supplemented  by  more  recent  work  in  dirigible  air- 
ships and  aeroplanes.  Observations  have  also  been 
made  in  large  steel  chambers  from  which  the  air 
has  been  gradually  pumped  out,  thereby  bringing 
about  the  conditions  of  diminished  air  pressure  and 
lack  of  oxygen  corresponding  to  definite  altitudes. 
Another  and  more  practical  method  of  observing  the 
effects  of  diminished  oxygen  pressure  is  to  get  the 
subject  of  experiment  to  breathe  air  diluted  with 
varying  amounts  of  nitrogen.  Professor  Dreyer  has 
recently  designed  a  very  simple  and  effective  method 
on  these  lines.  It  has  the  great  advantage  that 
the  observer  is  not  himself  submitted  to  the  effects 
of  the  rarefied  air. 

The  diminution  of  atmospheric  pressure  has  in 
itself  practically  no  effect  upon  the  human  body. 
The  body  is  composed  approximately  of  70  per 
cent,  fluid,  and  any  alteration  in  external  pressure 
is  transmitted  equally  to  all  parts  of  the  body,  so 
that  no  effects  due  to  pressure  arise  within  the 

The  question  is  sometimes  raised  as  to  whether 
the  aviator  is  liable  to  an  "  air  disease  "  or  "  flying 


sickness  "  akin  to  "  caisson  disease  "  or  "  divers* 
palsy."  The  cause  of  caisson  disease  is  now  well 
known.  Men  who  have  to  do  their  work  under 
increased  air  pressure  dissolve  under  this  pressure 
a  considerable  amount  of  nitrogen  in  the  blood 
plasma.  If  the  pressure  be  diminished  too  rapidly, 
e.g.,  when  a  diver  is  brought  too  rapidly  to  the 
surface  or  men  are  released  too  quickly  from  a 
caisson,  minute  bubbles  of  gas  are  given  off  in  the 
blood  which,  by  lodging  in  the  muscles  and  joints, 
may  produce  pains  known  as  "  bends,"  by  damaging 
the  nervous  system  may  produce  paralysis,  or  by 
blocking  the  blood  vessels  of  the  heart  or  brain 
may  cause  death. 

In  the  case  of  flying  there  is  no  corresponding 
phenomenon,  because  even  at  a  height  of  20,000 — 
25,000  feet  the  diminution  of  pressure  is  not 
sufficiently  great  or  rapid  to  produce  any  liberation 
of  gases  dissolved  in  the  fluid  portion  of  the  blood. 

Diminution  of  pressure,  however,  may  produce 
certain  effects  upon  the  body  through  gases  more 
or  less  pent  up  within  it,  namely,  in  the  intestines 
and  in  spaces  connected  with  the  nose  and  the 
middle   ears. 

With  diminishing  atmospheric  pressure  any  gases 
that  there  are  in  the  intestines  will  expand  and 
occupy  a  larger  volume,  and  if  this  volume  is  at  all 
great  the  aviator  will  experience  a  distension  of 
his  stomach  and  intestines,  which,  by  pushing  up 
his  diaphragm,  may  cause  interference  with  his 
respiration.  But  inasmuch  as  the  amdunt  of  this 
gas  is  normally  not  large,  and  its  expansion  induces 
increased  contractions  of  the  intestines,  it  is  soon 
voided  from  the  body  and  inconveniences  from  this 
cause  are  rare. 

Generally  speaking,  little  attention  need  be  paid 
to  the  effects  due  to  expansion  of  the  gases  in  the 


alimentary  tract  beyond  exercising  a  certain  degree 
of  care  in  choosing  a  diet  which  does  not  cause  any 
upset  of  digestion,  especially  a  liberation  of  gases 
in  the  intestines.  In  this  respect  it  is  difficult  to 
specify  any  particular  forms  of  food,  since  these 
vary  in  gas-producing  power  with  individuals,  and 
each  person  is  more  or  less  aware  of  his  own  peculiarity 
in  this  respect. 

]More  important  from  the  point  of  view  of  the 
aviator  is  the  air  normally  enclosed  within  the 
middle  car,  and  in  the  air  spaces  connected  with 
the  nose.  The  alteration  in  pressure  in  the  frontal 
sinuses  causes  in  many  aviators  a  sense  of  discomfort 
amounting,  in  many  cases,  to  actual  headache  ; 
but  little  can  be  done  to  alleviate  this  condition. 

In  the  case  of  the  middle  ear,  if  the  Eustachian 
tubes  are  not  patent  and  equalisation  of  pressure 
is  not  easily  made,  a  most  unpleasant  train  of 
symptoms  may  ensue — noises  in  the  ears,  giddiness, 
and  even  severe  pain.  These  symptoms  are  due 
to  imequal  pressure  upon  the  ear  drum.  For  this 
reason  it  is  important  that  the  flying  officer  be 
taught  how  to  maintain  the  pressure  equally  on 
either  side  of  the  tympanic  membranes  normally. 
During  ascent  the  pressure  in  the  Eustachian  tubes 
may  be  diminished  by  forcibly  swallowing,  when  a 
clicking  may  be  heard  in  both  ears,  or  better  still,  by 
imitating  tlie  first  inspiratory  movement  of  a  yawn, 
when  a  cracking  note  is  experienced  in  the  ears. 
By  practice  it  becomes  possible  to  open  the  tubes 
without  opening  the  mouth.  During  descent  the 
pressure  may  be  equalised  in  much  the  same  way 
as  the  above,  since  each  swallowing  or  yawning 
movement  jigain  momentarily  opens  up  the  Eus- 
tachian tube  and  permits  an  equalisation  of  pressure 
to  t  ike  place.  Generally  speaking,  however,  during 
descent,    particularly    if   very    sudden,    tlie    pressure 


within  the  Eustachian  tubes  is  best  increased  by 
holding  the  nose  and  gently  blowing  up  the  tubes 
with  a  forced  expiratory  movement,  the  mouth 
being  closed.  When  planing  down  steeply,  it  is 
particularly  important  to  bring  about  this  regularisa- 
tion  of  the  air  pressure  as  frequently  as  possible. 

Prior  to  a  flight,  especially  to  high  altitudes, 
these  movements  may  be  practised  on  the  ground, 
namely,  by  alternately  swallowing  and  blowing  up 
gently,  with  the  nose  held  and  the  mouth  shut. 
Any  catarrhal  condition  of  the  nose  and  throat 
such  as  that  due  to  a  nasal  cold  or  to  excessive 
smoking  may  lead  to  blocking  of  the  Eustachian 
tubes.  For  this  reason  the  flying  officer  should  as 
much  as  possible  avoid  the  risk  of  catarrhal  infection. 

As  a  digression,  it  may  be  stated  for  the  informa- 
tion of  the  non-medical  reader,  that  "  colds  "  are 
not,  as  their  name  signifies,  due  to  cold.  Scott 
and  his  fellow-explorers  in  no  way  suffered  from 
common  colds  even  at  very  low  temperatures, 
excepting  when  parcels  of  clothing  containing  dust 
and  germs  were  opened.  A  cold  in  the  head  is 
due  to  the  thriving  of  certain  organisms  on  the 
lining  membranes  of  the  nose  and  throat  of  an 
individual  who  has  been  exposed  to  infection. 
These  are  generally  conveyed  in  minute  particles 
of  secretion  coughed  or  sneezed  into  the  air  by  a 
person  who  is  infected — ^the  person  exposed  to 
infection  will  not,  however,  develop  a  cold  unless 
the  microbe  is  of  a  peculiar  virulent  kind  or  his 
resistance  to  infection  has  been  reduced  by  a  low 
state  of  health,  or  unless  the  mucous  membranes 
have  been  prepared  for  infection  by  previous  con- 
gestion in  a  stuffy  atmosphere.  The  great  secret 
in  the  avoidance  of  colds  is  to  shun  (1)  stuffy  atmos- 
pheres, (2)  the  neighbourhood  of  infected  persons. 
Conversely,    an    infected    person    should    always    be 


careful  to  sneeze  or  cough  directly  into  a  handker- 
chief and  avoid  shouting  or  loud  speaking  when 
near  any  one. 

The  chief  effects  of  altitude  on  the  bodily  mechan- 
isms are,  however,  due  almost  entirely  to  the  dimin- 
ished oxygen  supply  in  the  air.  Roughly  speaking, 
at  an  altitude  of  11,000  feet,  the  air  contains  rela- 
tively only  two-thirds  of  the  oxygen  tension  it  does 
at  sea  level,  at  19,000  feet  only  one-half.  Thus  the 
aviator  flying  at  these  heights  will  have  to  increase 
his  intake  of  air  in  order  to  obtain  the  same  amount 
of  oxygen  that  he  would  get  at  sea  level.  This  he 
does  unconsciously  by  breathing  more  deeply  and 
more  quickly.  Every  one  who  has  flown  to  any 
height  knows  this  fact,  and  has  found  that  after  a 
certain  altitude,  he  is  no  longer  a  nose  breather,  but 
begins  to  breathe  deeply  through  both  mouth  and 
nose.  The  breathing  and  circulation  react  in  the 
same  way  as  they  do  when  heavy  work  is  being 
undertaken.  ^\^ien,  therefore,  an  aviator  is  at  a 
height  where  the  tension  of  oxygen  is  considerably 
reduced,  his  respiration  and  his  circulation  alter 
in  character  and  rate  in  order  to  keep  up  the  supply 
of  oxygen.  To  do  this  with  any  degree  of  success, 
an  aviator  must  have  both  a  sound  chest  and  a 
sound  circulatory  system,  and  the  examination  of 
successful  flying  officers  has  shown  that  they  are 
possessed  of  great  respiratory  and  circulatory  effi- 

The  effects  of  diminishing  oxygen  tension  may 
be  mentioned  in  more  detail.  In  an  atmosphere 
in  which  the  oxygen  has  been  reduced  from  the 
normal  20.97  to  17  per  cent.,  although  a  match  will 
not  burn,  a  man  feels  little  or  no  discomfort.  With 
14  per  cent,  of  oxygen  the  depth  of  breathing  is 
appreciably  increased,  the  blood  pressure  slightly 
raised,   and  the   pulse   rate   augmented.     With   per- 


centages  from  10  to  12,  a  form  of  nervous  exaltation 
appears,  approaching  in  many  cases  to  an  intoxica- 
tion, so  that  although  the  subject  has  the  greatest 
confidence  in  himself,  he  is  really  far  below  his 
normal  efficiency.  This  has  been  conclusively  proved 
both  for  atmospheres  in  which  the  oxygen  has  been 
altered  at  normal  pressure,  and  also  by  experiments 
in  rarefaction  chambers.  Persons,  however,  appear 
to  vary  considerably  in  the  degree  to  which  ^their 
mental  powers  are  affected.  In  many,  the  onset  of 
mental  symptoms  is  also  attended  by  a  feeling  of 
giddiness,  considerable  diminution  of  muscular  power, 
and  less  frequently  by  nausea  and  vomiting. 

Finally,  diminution  of  oxygen  tension  in  the 
atmosphere  leads  to  paralysis  :  as  in  the  case  of  the 
famous  balloon  ascent  of  the  aeronauts  Coxwell  and 
Glaisher,  when  both  aeronauts  became  suddenly 
paralysed.  Coxwell,  however,  managed  to  pull  the 
safety-valve  with  his  teeth,  and  thus  prevent  disaster. 
In  another  well-known  balloon  ascent,  Croce-Spinelli, 
Sivel,  and  Tissandier  were  all  paralysed  before  they 
began  to  breathe  the  oxygen  in  the  bags  with  which 
they  had  been  provided,  although  the  famous 
French  physiologist,  Paul  Bert,  had  warned  them 
not  to  wait  until  too  great  a  height  was  attained 
before  using  these  bags.  At  present  there  is  little 
danger  of  the  ordinary  aeroplane  reaching  the  heights 
necessary  for  such  symptoms  to  occur. 

From  this  it  will  be  seen  that  it  cannot  be  empha- 
sised too  strongly  that  the  effects  of  altitude  are 
in  reality  due  to  diminished  oxygen  tension,  and 
not  directly  due  to  diminished  pressure,  and  it  is 
obvious  that  the  first  thing  that  is  required  in  any 
flier  is  that  he  should  be  able  to  withstand  the 
strain  of  frequently  repeated  exposure  to  an  atmos- 
phere in  which  the  oxygen  tension  is  progressively 
diminishing.      In    other    words,    for    high    altitude 


flying,  he  must  be  able  partieularly  to  withstand 
wear  and  tear.  Since  the  strain  of  altitude  flying 
is  thrown  particularly  on  the  respiratory  and  circu- 
latory systems,  and  the  nervous  mechanisms  con- 
trolling them,  these  are  particularly  examined  in  the 
selection  of  the  flying  officer. 

A  number  of  the  tests  employed  for  these  have 
been  worked  out  by  the  examination  of  the  successful 
flying  officer.  In  the  main  these  are  of  a  simple 
natiux'.  One  such  test  is  the  breath-holding  test 
referred  to  elsewhere. 

The  examination  of  successful  aviators  has  also 
shown  that  a  good  vital  capacity,  that  is,  the  amount 
of  air  which  can  be  taken  into  the  lungs  after  the 
fullest  expiration  and  fullest  possible  inspiration, 
shall  be  sufficiently  large.  This  can  be  tested  by 
the  use  of  a  special  modification  of  an  ordinary  gas 
meter.  After  having  filled  the  lungs,  the  subject 
is  asked  to  expire  as  deeply  as  possible  through  the 
meter  and  the  amount  is  thereby  automatically 
recorded.  The  average  vital  capacity  of  the  success- 
ful pilot  is  about  4,000  c.c,  and  the  vital  capacity 
of  any  flying  officer  should  preferably  not  fall  below 
3,400  c.c,  and  certainly  not  below  3,000  c.c. 
whatever  be  his  physique. 

This  method  of  measuring  the  lung  capacity  is 
altogether  more  satisfactory  than  that  of  measuring 
the  chest,  which  may  give  quite  deceptive  results. 
An  apparently  narrow-chested  individual  may  often 
have  a  larger  vital  capacity  than  a  subject  who 
apparently  has  a  large  chest  capacity.  It  is  important 
also  that  the  candidate  for  aviation  shall  have  good 
chest  movement,  a  firm  abdominal  wall,  and  be, 
preferably,  a  deep  breather.  By  slow,  deep  breathing 
more  air  is  taken  into  the  lungs  than  by  more  rapid, 
shallow  breathing.  It  has  also  been  shown  that  the 
efficient  pilot  responds  by  slow,  deep  breathing  to 


work,  and  that  quick,  shallow  breathing  is  not  easily 

The  advantage  of  a  firm  abdominal  wall  for  good 
respiration  and  efficient  circulation  cannot  be  over- 
stated. Research  in  connection  with  successful  pilots 
has  shown  that  those  who  wear  well  have  good 
expiratory  force.  From  the  examination  of  successful 
pilots  a  standard  expiratory  force  has  been  found, 
namely,  the  height  to  which  a  column  of  mercury 
can  be  steadily  blown  in  a  U  tube  manometer. 
AVhen  flying  stress  is  supervening  the  power  to  blow 
up  mercury  is  appreciably  decreased. 

A  variant  of  this  test  is  to  note  the  time  during 
which  a  definite  pressure  of  mercury  can  be  sus- 
tained with  the  breath  held  and  nose  clipped.  The 
behaviour  of  the  pulse  may  also  be  watched,  and, 
from  the  nature  of  the  response,  valuable  information 
is  obtained  as  to  the  condition  of  the  subject  under 
examination.  The  U  tube  test  has  proved  of  value 
in  elucidating  the  condition  of  the  lungs,  heart,  and 
medullary  centres  in  successful  and  unsuccessful 
officers,  and  in  this  way  standards  have  been  set. 

Soundness  of  heart  is  as  essential  as  soundness  of 
wind.  Over  and  above  evidence  of  soundness  by 
the  ordinary  clinical  examination,  evidence  is  sought 
as  to  the  manner  in  which  the  heart  will  respond  to 
work.  In  flying  it  will  have  increased  work  thrown 
upon  it,  sometimes  in  a  very  rarefied  atmosphere, 
and  the  quicker  the  heart  beats,  even  at  ground  level, 
the  more  oxygen  it  requires. 

Under  stress  of  work  at  ground  level  the  heart 
beat  rises  frequently  to  100,  but  at  great  heights  the 
rate  is  frequently  considerably  more  than  this, 
which  means  that  under  these  circumstances  largely 
increased  oxygen  supply  is  necessary,  at  the  very  time 
when  a  lessened  supply  is  available. 

A  standardised  test  is  often  employed,  which  has 


been  worked  out  by  the  examination  of  successful 
pilots.  This  consists  in  raising  the  body  on  to  a 
chair  five  times  in  fifteen  seconds.  The  standard 
increase  which  takes  place  in  good  pilots  is  known, 
and  the  rate  of  return  to  normal  is  also  known,  and, 
from  the  response  given  by  the  subject,  an  idea  as 
to  whether  this  is  satisfactory  or  not  can  therefore 
be  assessed.  It  has  also  been  found  that  in  good 
pilots  the  diastolic  pressure  is  relatively  high,  and 
that  the  difference  between  this  pressure  and  the 
systolic  pressure  is  not,  as  a  rule,  more  than  30  to 
40  mm.  of  mercury.  In  any  case  the  difference 
between  these  pressures  should  not  be  too  great,  and 
the  diastolic  pressure  should  certainly  not  be  low 
(below  70  mm.  Hg.)  in  any  subject  passed  for  aviation. 

It  will  be  seen  that  in  the  examination  of  the 
candidate  considerable  reliance  is  placed  upon  in- 
strumental examination.  This  is  because  instru- 
mental examination  gives  definite  results  by  which 
another  medical  officer  at  a  subsequent  stage  in  the 
career  of  the  candidate  can  contrast  the  condition 
of  the  subject  with  his  previous  examination,  and 
see  whether  he  is  wearing  well  or  showing  signs  of 
stress,  and,  if  the  latter,  take  appropriate  measures 
to  prevent  breakdown.  For  this  reason,  all  such 
tests  should  be  of  the  simplest  possible  nature.  It 
is  to  be  emphasised  also  that  they  are  designed  to 
aid  the  examination,  and  that  the  results  obtained 
should  be  judged  in  the  light  of  the  results  of  the 
examination  as  a  whole. 

The  disabilities  resulting  from  flying  are  due 
almost  solely  to  the  wear  and  tear  on  the  organism 
as  the  result  of  the  repeated  and  intermittent  strain 
upon  the  nervous  system  and  the  respiratory  and 
circulatory  mechanisms.  This  fatigued  condition 
occurs,  although  less  frequently,  amongst  men  in 
the   line.     It    is,    however,    liable   to    appear    earlier 


amongst  flying  men,  because  they  are  living  under 
conditions  which  are  at  times  even  more  abnormal. 

The  examination  of  officers  suffering  from  Flying 
Stress  has  abundantly  proved  that  in  connection 
with  the  circulatory  and  respiratory  mechanisms 
signs  of  stress  supervene.  Particularly  character- 
istic is  a  degree  of  instability  associated  with  the 
medullary  centres.  This  is  particularly  well  show^n 
by  an  examination  with  the  U  tube  manometer. 

The  attention  of  the  flying  officer  cannot  be 
directed  too  often  to  the  fact  that  he  must  keep  his 
respiration  and  circulation  efficient  by  a  process 
almost  akin  to  that  of  training.  The  rower,  the 
mountaineer,  the  long  distance  runner,  the  swimmer, 
the  boxer,  in  fact  any  man  who  wishes  to  bring  off 
any  particular  performance,  is  obliged  to  train  his 
body.  In  the  same  way  it  is  incumbent  upon  the 
aviator  who  wishes  to  do  his  best  at  altitudes  more 
or  less  to  keep  himself  in  training.  Thus  deep 
breathing  can  be  cultivated,  the  expansion  and 
movements  of  the  chest  increased,  and,  to  a  certain 
extent,  the  habit  unconsciously  formed  of  breathing 
deeply  and  efficiently. 

For  this  purpose  slow  chest  exp«insion  exercises 
with  arm  movements,  as  provided  by  physical  train- 
ing, are  good.  At  the  same  time  a  healthy  outdoor 
life  is  necessary,  with  vigorous  games,  so  that  the 
subject  may  have  his  muscles,  including  his  heart, 
in  the  best  condition,  ready  and  fit  to  undertake 
any  amount  of  effort. 

Of  particular  value  from  this  point  of  view  are 
those  forms  of  sport  in  which  the  subject  performs 
vigorous  work  with  the  breath  held,  as,  for  example, 
boxing  and  under-water  swimming.  It  is  well  known 
that  experts  in  these  forms  of  sport  make  very 
efficient  high  altitude  fliers.  Cross-country  running 
and   football   are    also   to   be   recommended.     Since 


good  belly  muscles  are  important,  care  also  should 
be  taken  to  preserve  the  tone  of  these  by  suitable 

Attention  may  also  be  drawn  to  the  value  of  the 
hardening  of  the  body,  that  is,  accustoming  it  more 
or  less  to  exposure.  The  reason  that  flying  officers 
from  overseas  are  successful  in  flying  at  altitudes 
is  largely  because  they  have  not  "  coddled  "  them- 
selves but  have  been  accustomed  to  leading  a  life 
in  the  open,  wearing  often  a  minimum  of  clothing. 
Thus,  they  have  inured  their  bodies  to  withstand 
discomfort  arising  from  cold.  This  means  that 
when  exposed  to  the  cold  of  high  altitudes  there 
is  not  the  same  tendency  for  them  to  use  up  bodily 
fuel  extravagantly  in  order  to  keep  the  body  warm, 
and  there  is  a  consequent  lessening  of  the  oxygen 
required.  The  same  is  true  of  the  athlete  generally, 
and  there  is  no  need  to  emphasise  the  fact  that  the 
true  athlete  has  made,  and  is  still  making,  the  finest 
type  of  flier.  The  man  who  coddles  himself,  who 
likes  to  live  luxuriously,  too  warmly  clad,  who 
shirks  a  cold  dip  in  the  mornings,  is  not  the  man 
who  will  stand  the  strain  of  exposure,  or  fly  well  on 
long-distance  flights.  Cold  baths  each  morning  on 
arising,  the  avoidance  of  too  frequent  hot  baths, 
and  a  good  tramp  across  country  in  all  weathers 
have  their  value  in  this  hardening  process. 

The  introduction  of  the  use  of  oxygen  on  aircraft 
has  proved  of  incalculable  benefit  to  the  service. 
\Mien  administered  to  aviators  after  a  height  of 
15,000  feet,  in  such  a  manner  as  to  make  up  for  the 
deficiency  of  oxygen,  it  has  been  found  tliat  flying 
officers  are  able  to  keep  at  great  heights  in  com- 
parative comfort.  With  no  lack  of  oxygen,  there 
is  neither  respiratory  nor  cardiac  distress,  nor  is 
there  any  period  of  exaltation  or  of  confusion  of 
the  senses.     Before  the  use  of  oxygen,  aviators  some- 


times  returned  to  their  aerodromes  and  made  fan- 
tastic reports  as  to  the  numbers  and  height  of  hostile 
aircraft  seen ;  or  observers,  when  confronted  with 
photographic  plates  showing  several  exposures  on 
each,  believed  that  the  camera  was  at  fault,  since 
they  felt  sure  that  they  had  taken  only  one  photo- 
graph on  each  plate.  It  is  now  realised  that  such 
performances  were  probably  attributable  to  lack  of 
oxygen  and  the  consequent  confusion  of  the  senses. 
Without  the  use  of  oxygen,  many  fliers  found  it 
difficult,  on  account  of  muscular  weakness,  energeti- 
cally to  work  a  gun  or  to  release  it  when  jammed. 

Oxygen  can  be  carried  either  in  the  form  of  com- 
pressed gas  in  cylinders,  or  as  liquid  in  a  metal 
vacuum  vaporiser.  For  long-distance  machines 
the  latter  has  the  advantage  owing  to  the  lightness 
of  the  apparatus  and  the  amount  of  oxygen  that 
can  be  carried.  Oxygen  is  of  especial  value  in  long- 
distance bombing  and  high-flying  work,  when  the 
physical  strain  upon  the  airman  is  great. 

If  not  administered  during  the  flight,  the  adminis- 
tration of  oxygen,  when  practicable,  to  aviators  on 
landing  after  a  long  flight  is  also  of  value.  As  with 
the  long-distance  runner,  it  quickly  relieves  aay 
distress,  and  mitigates  after-effects.  There  is  some- 
times a  feeling  amongst  aviators,  as  amongst  sports- 
men, that  oxygen  is  a  "  dope."  This  is  not  so. 
Unlike  the  familiar  experiment  in  which  a  glowing 
chip  of  wood  bursts  into  flame  in  the  presence  of 
oxygen,  the  human  body  does  not  burn  at  a  quicker 
rate  as  the  result  of  an  extra  oxygen  supply.  Only 
a  relatively  small  amount  of  any  extra  oxygen  is 
taken  up  from  the  lungs  at  ground  level.  Most 
of  the  excess  is  breathed  out  again  into  the  surround- 
ing air.  The  aim'  of  giving  oxygen  at  high  altitudes 
is  to  supplement  the  deficit  at  those  altitudes.  But 
even  if  a  little  more  be  given,  there  is  no  question 


of  an  exhilaration  or  stimulation  of  the  body  with 
a  subsequent  reaction,  as  in  the  case  of  certain 
drugs.  There  is  no  danger  of  the  pilot  who  takes 
oxygen  developing  an  "  oxygen  habit  "  or  craving 
at  ground  level.  The  administration  of  oxygen  to 
normal  healthy  persons  makes  a  difference,  par- 
ticularly during  heavy  work,  because  the  heart 
works  more  efficiently  and  with  an  ample  oxygen 
supply  waste  products  are  fully  combusted,  and 
do  not  accumulate  within  the  body.  The  great 
service  of  oxygen  in  diseases  such  as  pneumonia 
is  so  well  known  as  hardly  to  need  mention.  This 
is  because,  owing  to  the  diseased  condition  of  the 
lungs,  the  heart  is  starved  for  oxygen.  Owing  to 
the  rarefied  air,  the  heart  and  the  body  are  starved 
at  great  heights,  and  the  administration  of  oxygen 
has  similar  beneficial  results.  Oxygen  may  be 
taken  by  means  of  a  mask  or  a  pipe  mouthpiece. 
The  mask  method  is  altogether  to  be  preferred  to  the 
pipe.  With  the  pipe,  care  must  be  taken  that  the 
flow  is  free,  that  the  oxygen  is  quickly  drawn  in 
without  the  expenditure  of  unnecessary  energy  in 
sucking.  A  combined  mask  and  pipe  may  be  used 
advantageously.  Oxygen  should  preferably  be  taken 
continuously  at  heights  of  10,000  feet  upwards,  the 
delivery  being  automatically  regulated  according 
to  the  height,  or  it  may  be  taken  intermittently, 
when  a  slightly  larger  amount  per  minute  is  taken 
for  several  minutes  and  its  use  then  stopped  for  a 
time  and  resumed  again  when  required.  As  stated, 
the  continuous  method  is  to  be  preferred,  since 
thereby  the  intermittent  strain  on  the  bodily  mechan- 
isms is  obviated. 

Another  effect  of  altitude  which  has  to  be  taken 
into  account  is  the  temperature  of  the  air.  Roughly 
speaking,  the  temperature  of  the  air  becomes  1°  F. 
colder  for  every  365  feet  of  climb,  so  that  at  high 


altitudes  very  extreme  cold  may  sometimes  have 
to  be  endured.  The  intensity  of  the  cold  varies 
with  the  season  of  the  year  and  with  the  height 
attained  ;  it  is  accentuated  also  by  the  speed  of  the 
machine  through  the  air.  To  prevent  loss  of  body 
heat  while  flying,  special  suits  have  been  designed, 
the  cardinal  principle  of  which  is  to  keep  the  body 
surrounded  by  layers  of  warm  air.  In  most  cases 
this  warmth  is  derived  from  the  body,  but  the 
warming  of  clothing  by  electric  means  has  also  been 
tried.  '  For  warmth  purposes  great  thickness  of 
clothing  is  by  no  means  necessary.  Underclothing 
should  be  loose  fitting  :  two  thin  garments  of  closely 
woven  texture,  either  of  wool  or  silk,  are  better 
than  one  thick  one.  Research  has  shown  that 
the  warmth-giving  power  of  clothing  lies  in  the 
fineness  of  the  mesh  rather  than  in  its  thickness. 
Care  should  be  taken  to  avoid  orifices  through  which 
the  outside  air  can  permeate.  Tight  clothing  should 
be  avoided,  particularly  clothing  which  tends  to 
hamper  the  movements  of  the  chest  or  restrict  the 
circulation  of  the  limbs.  On  active  service,  the 
flying  suits  issued  will  generally  be  found  to  fulfil 
all  requirements. 

Frequently,  however,  it  is  necessary  to  employ 
considerable  additional  protection  for  the  legs,  espe- 
cially for  the  feet,  and  for  this  reason  great  care 
should  be  taken  in  providing  suitable  additional  pro- 
tection in  the  form  of  warm,  loose-fitting  stockings. 

For  the  protection  of  the  face,  a  fairly  close- 
fitting  head  and  face  piece  of  non-absorbent  and 
non-porous  material  may  be  made,  the  inner  surface 
of  which  will  not  absorb  the  oil  or  grease  with  which 
it  is  imperative  to  anoint  the  face  when  severe  cold 
has  to  be  endured.  Over  such,  a  woollen  balaclava 
may  be  worn,  and  then  a  leather  cap  of  good  close- 
fitting  design. 


Most  flying  caps  have  the  defect  that  the  crown 
of  the  head  is  not  fur-lined.  Many  officers,  there- 
fore, will  find  it  an  increased  comfort  to  extend  the 
fur-lining  of  the  helmet  completely  over  the  crown 
of  the  head.  An  adequate  head  covering  should 
be  such  that,  when  the  cap,  goggles,  and  oxygen 
mask  are  employed,  the  face  is  entirely  covered. 
For  special  purposes,  there  is  being  issued  a  com- 
bined helmet  fitted  with  oxygen  mask  and  micro- 
phone attachment,  which,  with  the  goggles,  com- 
pletely envelopes  the  head  of  the  aviator,  and 
greatly  conduces  to  his  comfort.  Leakage  of  air 
around  the  neck  is  prevented  by  means  of  a  suitable 
scarf  or  fur  stole.  For  the  protection  of  the  hands 
a  series  of  suitable  gloves  may  be  employed,  for 
instance  thin  silk  gloves  covered  by  woollen  gloves, 
the  whole  enclosed  in  a  leather  gauntlet,  which  can 
be  easily  removed  for  delicate  work.  Gauntlets 
provided  with  a  specially  adaptable  finger  muff  are 
to  be  recommended.  In  certain  cases  electrically 
heated  gloves  have  also  been  employed. 

For  the  protection  of  the  eyes  well-fitting,  fur-lined 
triplex  goggles  should  be  employed.  The  fogging 
of  goggles  may  be  prevented  by  certain  preparations 
which  are  on  the  market.  Certain  pilots  prefer  to 
employ  tinted  goggles,  and  for  this  purpose  a  special 
issue  has  been  made.  It  is  claimed  that  such 
goggles  arrest  harmful  rays  which  tender  to  produce 
inflammation  of  the  conjunctiva  and  also  enable 
many  pilots  to  observe  objects  in  greater  detail. 
Some  aviators  take  a  considerable  time  to  get 
accustomed  to  the  employment  of  such  glasses. 

In  conclusion,  a  few  other  hints  may  be  incor- 
porated here.  Every  flying  officer,  especially  when 
on  active  service,  sliould  endeavour  to  fill  up  his 
spare  time  in  a  way  which  rests  his  mind  and  takes 
away    liis    thoughts    from    his    work.      A\1u'n     the 


flying  hours  are  long,  exercise  should  be  particularly 
directed  to  employing  those  muscles  which  are  not 
fatigued  in  flying.  Such  exercises  are  riding,  cross- 
country walks,  and  a  certain  amount  of  football. 
A  hobby,  according  to  the  tastes  of  the  individual, 
is  an  excellent  mental  distraction,  preferably  one 
which  takes  the  subject  into  the  open  air.  When 
games  such  as  billiards  and  cards  are  indulged  in, 
stuffy  atmospheres  should,  as  far  as  possible,  be 

Just  as  in  training  for  sport,  the  flying  officer 
should  endeavour  to  get  regular  hours  of  sleep  in  a 
well-ventilated  chamber,  no  matter  how  great  be 
the  temptation  to  break  the  rule.  Adequate  hours 
of  rest  are  all  important.  Although  every  measure 
should  be  taken  to  ensure  adequate  warmth  during 
sleep,  there  is  frequently  a  tendency  to  employ 
too  much  bed  clothing,  which  to  a  certain  extent  has 
the  same  effect  as  "  coddling."  As  with  clothing, 
it  is  possible  to  accustom  the  body  to  a  minimum 
amount  of  protection  necessary  to  preserve  the 
body  warmth. 

After  a  flight  the  recumbent  posture  is  restful 
to  the  fatigued  bodily  mechanisms.  If  difficulty  be 
experienced  in  going  to  sleep,  the  Medical  Officer 
can  give  useful  advice. 

It  has  already  been  hinted,  in  regard  to  diet,  that 
gas-producing  foods  are  best  avoided,  but  in  practice 
there  is  little  need  for  the  average  healthy  person 
to  w^orry  about  the  constitution  of  his  diet.  It 
is  important,  however,  that  no  flying  should  under 
any  circumstances  take  place  upon  an  empty  stomach. 
It  is  quite  probable  that  a  number  of  the  accidents 
which  occur  during  training  are  due  to  the  fact  that 
the  pupil  has  not  partaken  of  an  adequate  meal 
before  venturing  into  the  air. 

Before  long  ffights  it  is  advisable  not  to  partake 


of  food  of  too  fluid  a  nature  or  of  too  much  liquid. 
By  this  means  the  desire  to  urinate  in  the  air  during 
a  flight  is  avoided.  On  very  long  flights,  especially 
on  two-seater  machines,  a  supply  of  liquid  food,  such 
as  sweetened  cocoa  or  malted  milk,  may  be  carried 
in  special  thermos  flasks.  In  addition  compressed 
food  in  the  form  of  tablets  or  chocolate  may  be 

Tobacco  and  alcohol  also  have  their  importance 
as  regards  the  question  of  training  and  well-being, 
and  for  this  reason  too  much  stress  cannot  be  laid 
upon  the  importance  of  over-indulgence  in  either. 
Excessive  smoking  of  cigarettes,  especially  the  in- 
haling of  the  smoke,  produces  shortness  of  breath 
and  quickening  of  the  heart  beat.  As  anything 
which  interferes  with  the  breathing  is  particularly 
harmful  to  the  flying  man,  there  is  little  need 
to  labour  this  point.  Anyone  who  has  become 
accustomed  to  inhaling  should  be  advised  to  give  up 
cigarettes  and  take  to  a  pipe,  and,  generally  speaking, 
an  endeavour  should  be  made  by  the  flying  officer 
to  reduce  smoking  to  a  minimum,  since  any  excess 
impairs  the  action  of  the  respiratory  and  circulatory 
systems,  which  are  of  such  vital  importance  to  the 
aviator.  Smoking  is  too  often  an  expression  of 
sociability  at  the  expense  of  efficiency.  The  "  gasper  " 
or  the  "  yellow  peril  "  are  best  avoided  when  the 
flying  officer  is  lianging  around  on  the  tarmac  ;  indeed 
smoking  is  best  given  up  altogether. 
'  The  question  of  alcohol  is  even  more  difficult  than 
smoking.  Undoubtedly  alcohol  is  best  avoided  by 
the  flying  officer.  There  is  no  doubt  that  on  the 
return  from  a  fatiguing  ffight,  especially  during 
bad  weather,  there  is  a  great  call  for  a  "  stimulant." 
The  unsatisfactory  things  about  alcohol  are  (1)  that 
in  many  people  one  drink  begets  a  desire  for  another, 
and   that   a   greater  amount   is  gradually   necessary 


to  produce  the  desired  effect ;  (2)  that  this  effect 
is  too  evanescent.  Experimental  work  on  the  effects 
of  alcohol  upon  the  human  body  sho^v  that  from  the 
point  of  view  of  efficiency  the  so-called  beneficial 
effects  are  entirely  illusory.  The  judgment  is  affected, 
*'  reaction  time  "  is  slowed,  and  fine  co-ordination  of 
movement  impaired.  The  importance  of  this  to 
the  aviator  is  at  once  apparent.  To  avoid  disaster 
he  has  always  to  be  on  the  '*  qui  vive  "  and  ready 
at  the  shortest  notice  to  put  into  necessary  action, 
by  relatively  delicate  muscular  movements,  any 
message  which  reaches  his  brain. 

The  above  applies  particularly  to  what  may  be 
termed  "  steady  drinking  "  of  a  degree  insufficient 
to  produce  intoxication.  It  is  not  suggested  that 
an  occasional  convivial  evening  is  in  itself  productive 
of  great  harm  to  the  system,  particularly  if  it  is 
certain  that  no  flying  shall  take  place  while  the 
body  is  still  under  the  influence  of  the  drug.  On 
the  other  hand,  the  idea  of  priming  up  the  system 
by  alcohol  before  a  flight  is  wholly  pernicious  and 
cannot  be  too  strongly  condemned.  Such  a  course, 
even  in  the  strongest,  cannot,  if  habitually  persisted 
in,  end  otherwise  than  in  disaster. 


The  Psychology  of  Aviation 

From  the  point  of  view  of  medical  interest  there  is 
perhaps  no  more  important  subject  than  the  study 
of  the  psychology  of  flying,  in  that  the  practical 
issues  at  stake  are  so  great.  From  the  study  of  the 
sensations  experienced  during  flight  the  medical 
officer  is  able  to  gain  a  wealth  of  information  of 
inestimable  value  to  him  in  dealing  with  his  flying 
charges.  Mention  need  only  be  made  of  its  value 
in  selecting  the  best  type  of  men  suitable  for  aviation 
duties,  in  advising  and  helping  the  pupil  aviator 
during  his  period  of  instruction,  in  noting  any  change 
in  his  mental  attitude  towards  flying,  in  intervening 
where  loss  of  confidence  is  beginning,  and  prevent- 
ing the  establishment  of  a  definite  aeroneurosis,  in 
detecting  the  malingerer,  in  co-operating  with  the 
instructors,  and  finally  in  the  treatment  and  disposal 
of  those  who  liave  broken  down  through  stress  of 

The  spirit  of  conquest  has  throughout  the  ages 
been  found  among  a  certain  class  of  men — pioneers, 
adventurers,  supermen,  or  even  madmen  have  they 
been  styled,  as  tlie  fancy  pleased. 

Handed  down  from  our  fighting  ancestors  this 
spirit  of  conquest,  unchanged  by  environment  or 
circumstances,  and  kept  alive  by  the  law  of  survival 
of  the  fittest,  finds  itself  to-day  living  with  renewed 
vigour   in    the   realms   of   aviation.     Man's   fight   to 



conquer  the  elements  has  been  prompted  either  by 
the  sense  of  sport  and  adventure  or  by  the  develop- 
ment of  commerce  in  the  spread  of  civilisation. 
And  ever  attendant  on  this  spirit  of  conquest  has 
been  the  cry  for  movement,  novelty,  and  speed. 
This  is  exemplified  in  man's  conquest  of  the  sea  from 
the  time  he  embarked  on  his  frail  craft  to  the  present- 
day  fast  going  ocean  liner  or  warship  ;  and  again 
the  call  for  novelty  and  speed  has  still  further 
been  appeased  by  man's  conquests  in  the  depths 
of  the  sea  in  his  development  of  the  modern 

No  less  have  been  his  conquests  on  land  since  the 
first  steam  locomotive  to  the  present-day  express 
train  doing  60  miles  an  hour.  More  speed  has  been 
attained  in  the  development  of  the  motor  car,  in 
road  and  track  racing,  demanding  of  man  very  high 
qualities  of  courage  and  alertness. 

Even  more  has  been  demanded  of  him  in  his  final 
conquest,  that  of  the  air,  necessitating  his  control  of 
great  speed  through  an  element  of  many  of  the 
factors  governing  the  navigation  of  which  he  is  as  yet 
ignorant.  There  is  no  doubt  that  the  early  pioneers 
of  flying  were  regarded  as  possessing,  in  their  ability 
to  fly,  some  supernatural  power,  and  were  looked 
upon  by  many  as  being  mad.  But  there  was  so  much 
method  in  their  seeming  madness  that  it  has  made 
possible  aviation  of  to-day  with  the  recognition  of 
the  vast  and  terrible  powers  the  Air  Force  possesses 
in  warfare,  and  also  the  possibilities  of  new  develop- 
ments in  commerce  and  travel. 

.  Although  from  the  first  aeroplane  flight  to  the  present 
day  covers  a  period  of  exactly  15  years,  flying  has 
really  only  been  before  the  public  for  a  little  over  ten 
years.  In  the  first  six  of  these  years  the  individuals 
who  had  actually  flown  either  as  pilots  or 
as    passengers  were   comparatively  few.     Up  to  the 


outbreak  of  the  present  war  only  862  Royal  Aero 
Club  Aviation  Certificates  in  this  country  had  been 
granted.     It  is  rather  difficult  to  estimate,  but  the 
total  of  half  a  million  probably  represents  the  number 
up  to  the  present  who  have  actually  flown  either  as 
pilots    or    observers.     Naturally    the    various    types 
who  have  taken  up  flying  are  not  all  equipped  with 
the  same  amount,   range   of   and  control  over  their 
imaginations,  nor  do  all  come  through  the  same  kind 
of    experiences    in    flying.     For    example    a    great 
difference  exists  in  the  sensations  experienced  in  an 
ordinary    quiet    passenger    flight    from    those    gone 
through  in  a  first  flight  with  the  type  of  pilot  whose 
one  thought    is    to    raise    "  vertical   gusts "    in    his 
companion.     Again    the    pupil    aviator    during    his 
period  of  instruction  may  meet  with  varied  types 
of  instructors  ;    and  here  the  author  would  ask  those 
specially  employed  as  instructors  to  realise  in  their 
speciality,   apart   from  the  requisite   flying  ability, 
patience  and  endurance,  that  success  will  come  to 
them   more   readily   through   a   close    study   of   the 
psychology   of  flying.     Many  instructors  are  young 
in  years,  but  the  nature  of  their  calling  tends  to  make 
them    psychologically    mature.     If    the    instructor's 
mind  is  solely  centred  in  his  pupil's  ability  to  learn 
either  quickly  or  easily  the  aeroplane's  control  during 
flight  his  interest  and  success  will  never  be  so  great 
as   when   he  pays  equal   attention  to   studying  the 
temperament  of  his  flying  charge.     Unless  he  does 
so  he  is  liable  to  undermine  his  own  pupil's  confidence 
in  him,  and  once  that  goes  there  is  little  hope  of  success 
for  the  pupil.     Indifference,  lack  of  sympathy,  diffi- 
culty of  approach,  or  bullying  methods  on  the  in- 
structor's part  may  absolutely  ruin  a  pupil's  flying 
career.     It  is  in  this  early  period  that  opportunities 
to  confide  in  those  more  experienced  greatly  jielp  a 
pupil,  for  it  must  be  remembered  that  he  is  not  only 


lonely  in  the  air  but  frequently  extremely  lonely  on 
the  ground.  The  threshold  in  flying  is  often  of  a 
frail  nature,  and  to  cross  it  a  firm,  helping  hand  may 
be  all  that  is  needed.  Failing  this,  a  slip  or  fall  occurs, 
and  the  whole  mental  attitude  towards  flying  may 
change.  The  stage  of  instruction  is  one  in  which 
the  impressions  gathered  may  mould  the  whole  future 
flying  life  of  the  pupil. 

Similarly  the  sensations  experienced  in  active 
service  flying  may  vary  greatly,  depending  upon  the 
type  of  flying  duties.  Within  the  short  space  of  a 
few  minutes,  concentrated  Hell  may  be  the  experience 
of  one  pilot,  whilst  another  may  carry  on  for  long 
spells  and  encoimter  no  such  horrors.  For  example 
a  night  bomber  may  make  many  raids,  fortunate 
always  in  weather  conditions,  a  good  engine,  and  the 
fact  that  the  enemy  searchlights  have  failed  to  pick 
him  up  ;  on  the  other  hand  a  machine  on  artillery 
observation  may  be  set  on  fire  or  partially  decon- 
trolled, and  have  the  greatest  difficulty  in  reaching 
its  own  lines,  being  perhaps  pursued  by  enemy  air- 
craft all  the  way,  and  made  a  target  for  a  never 
ceasing  hail  of  lead.  The  many  and  varied  expe- 
riences recounted  of  aerial  warfare  will  ever  remain 
a  wonderful  and  glorious  epic  in  history. 

In  order  to  study  the  psychology  of  flying,  the 
medical  officer  should  have  experience  of  the  air, 
preferably  as  a  passenger.  He  who  would  probe 
the  subject  more  deeply  can  only  do  so  by  having 
piloted  an  aeroplane  by  himself.  One  does  not 
advocate  that  all  R.A.F.  medical  officers  should 
learn  to  fly,  but  the  interest  in  their  work  will 
be  heightened  by  making  occasional  passenger 

Apology  must  be  made  by  the  author,  whose  work 
in  life  has  been  always  in  surgery,  for  venturing  to 
^vrite    on    such    a    difficult    subject    as    psychology. 


But  once  one  has  turned  the  handle,  and  pushed  tlie 
door  ever  so  little  ajar  to  peep  within,  one  must 
perforce  enter  this  fascinating  domain  and  relate 
in  no  matter  how  crude  a  way  one's  impressions  of 
the  visit. 

As  the  subject  of  psychology,  even  though  it  be 
a  specialised  department  of  the  subject,  is  apt  to 
lead  a  writer  into  generalities,  the  author  proposes, 
keeping  the  practical  issues  mainly  in  view,  to  deal 
with  the  subject  from  three  points  of  view  ;  namely 
(1)  from  that  of  the  passenger  or  pupil  during  his 
period  of  dual  control  instruction  ;  (2)  from  that 
of  the  pupil  aviator  during  his  first  few  solo  flights, 
and  (3)  from  that  of  the  qualified  aviator  engaged 
either  in  the  various  special  duties  of  war  flying  or  in 

Through  these  stages  one  can  study  the  various 
impressions,  sensations,  and  mental  deductions  and 
attitudes  in  flying,  and  finally  arrive  at  some  points 
of  practical  value. 

(1)  The  ordinary  individual  or  pupil  views  his 
first  passenger  flight  with  mixed  feelings,  the  nature 
and  intensity  of  which  depend  on  many  factors. 
Firstly  there  is  the  motive  which  prompted  him  to 
go  up  in  the  air.  The  investigation  of  this  motive 
is  an  important  one,  and  the  reason  why  flying  was 
chosen  formed  one  of  the  stock  questions  in  selecting 
candidates  for  aviation  duties.  The  pioneer  aviators 
were  undoubtedly  prompted  by  the  spirit  of  conquest, 
those  immediately  following  them  by  a  sense  of 
adventure  or  a  demand  for  excitement,  whilst  in 
others  later  by  scientific  curiosity  or  perhaps  financial 
possibilities.  With  the  outbreak  of  war  came  the 
motive  of  conquest  not  of  the  air  but  in  the  air. 
The  following  is  a  record  made  of  the  reasons  why 
flying  was  chosen,  from  100  consecutive  pupils  at  a 
large  flying  school. 


1.  Because  of  their  interest  in  flying 

2.  Because  of  the  attraction  or  fascination  of  flying 

3.  Because  of  a  desire  for  excitement 

4.  Because  of  the  novelty  of  flying 

5.  Because  of  a  mechanical  interest 

6.  Because  of  a  desire  for  change  from  the  infantry 

or  trench  life 

T.  Because  of  a  desire  for  experience  or  new  study 

8.  Because  of  the  possibilities  for  individual  action 

9.  Because  aviation  was  thought  the  best  branch  of 

the  service 

10.  Because  of  no  particular  reason 

11.  Because  of  a  liking  for  speed  ... 

12.  Because  of  a  financial  reason  ... 

13.  Because  of  physical  disability 

14.  Because  the  individual  felt  best  suited  for  flying 






In  reviewing  these  one  finds  that  the  majority, 
46  in  number,  take  up  flying  either  because  they  are 
interested  (30)  or  because  they  arc  attracted  (16). 
Those  that  take  it  up  for  excitement  (10),  for  novelty 
(8),  for  the  love  of  speed  (3),  for  the  opportunities  for 
indiviflual  action  (4),  form  another  group,  25  in 
number  ;  and  these  for  the  most  part  turn  out  to  be 
the  best  fighting  pilots.  Those  taking  it  up  for  the 
sake  of  mechanical  interest  (6),  for  experience  or  as  a 
study  (4),  or  for  service  reasons  (4),  form  another 
group  numbering  14.  Those  taking  it  up  for  purely 
self  reasons  may  be  grouped  together,  such  as  those 
desiring  a  change  from  trench  life  (6)  or  on  account 
of  financial  possibilities  (3),  numbering  9  in  all. 

Reasons  13  and  14  may  be  passed  over  without 
comment,  but  it  is  difficult  to  understand  the  men- 
tality of  those  who  take  up  flying  for  no  particular 

When  the  time  for  the  actual  flight  approaches  the 
motive  is  probably  relegated  to  the  background  of  the 


mental  picture,  but  later  and  throughout  the  flying 
career  it  may  continuously  assert  itself. 

The  second  factor  that  comes  into  play  is  the 
question  of  confidence  in  the  pilot.  This  is  of  import- 
ance, as  to  the  ordinary  individual  in  his  first  flight 
there  is  a  sense  of  danger,  conscious  or  subconscious. 
This  may  assert  itself  or  not,  depending  on  the 
amount  of  confidence  or  lack  of  it  in  his  pilot  or 
instructor.  Happily  confidence  in  the  machine  is 
of  little  import,  as  ignorance  with  regard  to  construc- 
tion and  aerodynamics  proves  a  wonderful  analgesic. 
The  question  of  confidence  in  his  pilot  having  been 
more  or  less  settled,  the  intending  passenger  finds 
himself  tuned  up  to  a  varying  state  of  excitement, 
as  evidenced  by  an  increase  of  10  beats  or  so  in  the 
pulse,  consciousness  of  the  heart's  action,  and  perhaps 
abdominal  sinking  sensations.  He  tries  to  answer 
to  himself  the  questions  what  will  the  flight  be  like, 
and  has  he  any  knowledge  of  what  he  is  about  to 
"  buy."  As  most  people  now-a-days  have  seen  an 
aeroplane  in  flight,  the  memory  of  previous  observa- 
tions is  awakened,  and  by  a  process  of  association 
the  two  first  attributes  that  will  enter  his  mind  are 
height  and  speed.  The  number  of  aeroplane  flights 
he  has  seen  and  whether  he  has  viewed  these  from 
near  or  far  will  determine  the  character  of  his  per- 
ceptions of  these.  It  is  at  first  difficult  for  the 
onlooker  in  aerodrome  life  to  estimate  with  any 
degree  of  accuracy  either  a  machine's  height  or  speed 
at  a  given  moment.  As  most  people  dislike  looking 
down  from  a  height  and  suffer  from  more  or  less 
vertigo  and  other  unpleasant  sensations,  one  of 
the  main  introspective  difficulties  will  be  with 
regard  to  how  he  can  withstand  this.  Again  memory 
of  speed  sensations  is  stimulated  by  past  experiences 
as  in  switchback  and  mountain  railways,  water- 
chutes  and  lifts.     As  he  approaches  the   aeroplane 


his  thoughts  are  to  a  certain  extent  diverted  from 
speed  and  height  for  the  moment  to  the  efforts 
made  in  cUmbing  into  the  passenger  seat,  fixing  the 
safety  belt  and  generally  making  himself  comfortable 
in  his  new  surroundings.  As  the  propeller  is  swung 
and  the  engine  started  his  impressions  become  mostly 
auditory.  These  increase  as  the  hum  of  the  engine 
mounts  to  a  roar  when  the  pilot  opens  the  throttle 
to  test  the  engine  and  gain  the  proper  number  of 
revolutions.  Mixed  with  the  auditory  impressions 
are  tactile  ones  from  the  vibration  of  the  whole 
machine,  and  from  the  rush  of  air  from  the  propeller. 
The  aeroplane  is  still  prevented  from  moving  for- 
ward by  the  chocks  placed  against  the  undercarriage 
wheels.  Then  the  engine  is  throttled  down  for  the 
moment,  the  chocks  are  removed,  and  as  the  throttle 
is  again  opened  the  aeroplane  moves  forward  to 
commence  its  flight.  As  it  progresses  on  and  over 
the  ground  the  passenger  is  conscious  of  the  aug- 
mented speed  and  vibration,  but  just  as  the  aero- 
plane leaves  the  ground  these  impressions  are 
suddenly  and  almost  completely  withdrawn.  The 
ground  and  objects  thereon  appear  to  be  moving 
away  but  this  perception  diminishes  as  the  machine 
gains  height.  On  looking  over  the  side,  the  pas- 
senger is  agreeably  surprised  to  find  that  he  can 
view  the  ground  with  equanimity  from  a  height  and 
experience  no  giddiness  or  other  unpleasant  sensa- 
tion. This  is  due  to  the  fact  that  the  aeroplane 
is  not  connected  with  the  ground  and  thus  the 
observer's  sense  of  perspective  is  altered. 

Although  the  aeroplane  may  be  flying  level  at 
from  60  to  120  miles  an  hour,  the  passenger  is  not 
conscious  of  any  such  speed  and  can  only  partially 
realise  this  by  projecting  his  face  or  hand  over  the 
side,  from  under  cover  of  the  wind  screen. 

His   anxieties   with   regard   to   height   and   speed 


having  been  relieved,  there  supervenes  a  feehng  of 
exhilaration  and  more  attention  is  now  paid  to  the 
scenery  below.  He  now  finds  mental  oecupation 
in  trying  to  adapt  his  new  perceptions  of  objects 
on  the  ground  and  comparing  and  contrasting  these 
with  his  previous  perceptions  at  ground  level.  As 
the  aeroplane's  course  is  altered  he  is  conscious  of 
one  wing  going  gently  up  as  the  whole  machine  is 
banked  in  turning.  Then  after  a  while  he  may 
become  a  little  apprehensive  of  the  descent,  and 
wonder  as  to  whether  he  will  experience  water- 
chute  or  lift  sensations.  Again  in  this  he  is  greatly 
surprised.  As  the  aeroplane's  nose  is  gently  pointed 
downwards  and  the  engine  throttled  down,  auditory 
impressions  are  diminished,  but  there  is  no  sensation 
of  rapid  descent  or  falling.  Nearing  the  end  of  the 
glide  the  earth  seems  to  be  coming  up  rapidly  to 
meet  the  aeroplane  and  the  sensation  of  speed  is 
again  increased.  As  the  wheels  touch  the  ground 
with  an  almost  imperceptible  jar,  the  vibrations 
increase  for  a  little,  and  then  subside  as  the  aero- 
plane slows  down  and  comes  to  rest.  When  the 
passenger  steps  out  he  is  conscious  of  a  marked 
sense  of  exhilaration  as  though  he  had  partaken  of 
a  glass  of  good  champagne.  The  pulse  is  found 
increased  from  10  to  20  beats  above  normal  and 
there  may  be  a  certain  amount  of  difhculty  in  hearing 
and  buzzing  in  the  ears.  The  mental  summing  up 
,of  most  passengers  after  a  flight  is  a  sense  of  exhilara- 
tion, a  feeling  of  having  accomplished  something, 
agreeable  surprise  at  the  absence  of  sensations  of 
height  and  speed,  mixed  with  mild  disappointment 
that   all   previous  apprehensions  were  needless. 

As  more  flights  are  taken  the  passenger  gains  what 
is  known  as  air  experience,  adapting  liimself  to  the 
various  evolutions  and  deriving  therefrom  more  or 
less  pleasure  as  the  case  may  be. 


With  the  pupil  under  instruction  the  case  is 
different.  As  well  as  accustoming  himself  to  being 
in  the  air  he  has  gradually  to  learn  how  to  control 
the  aeroplane  in  flight.  This  takes  a  varying  time 
from  2j  to  9  hours'  flying.  During  this  time  he  is 
fully  occupied  mentally  in  adapting  himself  to  a  new 
and  complex  set  of  co-ordinated  movements,  as  in 
working  in  unison  the  rudder  bar  with  his  feet  and 
the  control  lever  with  his  hand.  He  has  to  develop 
"  hands  "  or  delicacy  of  touch.  To  a  few  this  seems 
to  develop  easily  and  naturally.  Most  pupils  expend 
too  much  muscular  energy  on  the  controls,  "  squeeze 
juice  out  of  the  joy  stick,"  and  are  apt  to  over- 
correct  any  errors  in  the  air.  A  drowning  man  will 
clutch  at  a  straw,  and  the  author  is  inclined  to  think 
that  where  the  subconscious  element  of  fear  is  more 
marked  there  will  be  found  less  delicacy  of  control. 
Confidence  in  his  instructor  and  a  sense  of  rivalry 
and  competition  with  his  fellow-pupils  greatly  help 
the  would-be  aviator  at  this  stage — on  the  other 
hand  the  difficulty  of  estimating  how  far  he  him- 
self, and  not  his  instructor,  is  really  controlling 
the  machine  often  raises  doubts  in  his  mind  as  to 
his  progress  in  flying.  A  few  may  give  up  at  this 
stage,  realising  their  inability  to  learn,  or  finding 
themselves  unhappy  in  the  air,  losing  confidence 
in  themselves  and  recognising  that  their  nervous 
system  is  not  equal  to  the  strain.  Happily  most  are 
keen  and  determined  and  enjoy  their  lessons  in 
flying,  and  here  the  original  reason  why  flying  was 
chosen  exerts  no  little  influence  on  the  whole  problem. 
In  the  tuition  period,  confidence  as  a  rule  grows 
daily  until  the  pupil  realises  that  it  is  nearly  time 
for  him  to  be  sent  up  alone.  This  is  a  critical  period 
and  in  some  cases  quite  a  mental  strife  goes  on  ; 
a  fight  on  the  one  hand  between  determination  and 
a  desire  to  get  it  over,  and  on  the  other  a  feeling  of 


iincertaint}'  as  to  one's  ability  to  really  bring  it  off 

Sooner  or  later  the  momentous  da}^  in  the  pupil's 
flying  career  arrives,   and  this  brings  us  to   study. 

(2)  The  psychological  aspects  from  the  point  of 
view  of  the  pupil  on  his  first  solo. 

A  thorough  insight  into  this  side  of  the  question 
can  only  be  obtained  by  having  flown  solo  oneself. 
The  author's  own  effort  was  amply  repaid,  and  from 
a  careful  analysis  of  it  immediately  afterwards  he  was 
enabled  more  easily  to  pick  out  the  salient  psychologi- 
cal points  for  investigation  and  to  draw  up  a  scheme 
for  such  accordingly.  The  following  is  a  brief  resume 
of  his  own  experiences.  "  I  had  no  intimation  that  I 
was  to  go  Solo,  but  had  been  going  round  doing 
landing  practice  with  my  instructor,  Flight-Com- 
mander McMinnies,  when  after  the  fourth  landing 
he  got  out  of  the  machine,  as  I  thought,  to  examine 
a  tyre,  but  instead  said, '  Go  on,  "  doc,"  push  off,  you'll 
be  alrioht.'  I  knew  that  debate  and  delav  would 
raise  doubts  in  my  mind,  so,  to  avoid  this,  thankful 
that  I  had  not  been  given  long  to  ponder,  I  pulled 
down  the  mental  blind  on  my  imagination  and 
opened  the  throttle  slowly.  My  effort  at  taking 
off  the  ground  was  not  exactly  classical  and  I  found 
tlie  machine  slewing  off  to  the  left."  Although 
torque  is  mainly  responsible  for  this,  and  one  should 
correct  against  it  by  keeping  on  a  little  right  rudder, 
tlie  author  is  convinced  that  lack  of  co-ordinated 
movement  was  also  responsible.  In  the  forward 
movement  of  the  left  arm  to  open  the  throttle  there 
is  inclined  to  be  a  similar  automatic  action  of  the 
left  leg,  and  so  more  pressure  is  exerted  on  the 
left  rudder  bar,  causing  the  whole  machine  to  move 
to  the  left.  "  Once  in  the  air  my  mind  was  fully 
occupied  all  the  time  in  attention  to  flying,  watching 
controls,  instruments,  etc.,  and  I  can  honestly  say 


that  fear  had  no  time  to  assert  itself.  The  element 
of  fear  was  lurking  somewhere  at  the  back  of  the 
head,  but  acting  rather  as  a  guardian  spirit  in  making 
me  conscious  of  danger  and  concentrate  on  avoiding 
errors.  I  found  actual  flight  fairly  easy,  in  fact  the 
aeroplane  seemed  to  do  it  all,  and  all  I  had  to  do 
was  to  concentrate  in  case  any  emergencies  should 
arise."  Of  course  the  machine  feels  much  lighter, 
easier  on  the  controls  and  inclined  to  climb  more 
quickly  than  during  a  dual  instruction  flight.  In  a 
first  solo  there  is  no  time  to  notice  any  sense  of 
loneliness.  A  remnant  of  the  old  spirit  of  conquest 
reasserts  itself  in  that  one  has  time  to  feel  one  has  at 
least  achieved  something  new  and  wonderful.  In  a 
double  sense  one  feels  well  above  one's  fellow-creatures 
below.  "  After  two  circuits  I  determined  to  land — 
a  long  experience  of  aerodrome  life  told  me  that 
here  difficulties  arise,  but  I  was  too  occupied  mentally 
to  worry.  My  flying  friends  who  witnessed  my  first 
flight  will  all  agree  that  my  effort  to  land  was  not 
according  to  the  book  of  words.  I  made  many 
errors  in  the  descent  and  realised  that  stimuli  in 
rapid  succession  were  being  sent  to  the  higher  centres. 
There  was  no  time  to  be  afraid.  Each  stimulus 
of  difficulty  or  error  had  to  be  met  by  a  rapid  and 
correct  response.  On  landing  there  was  a  feeling 
of  happiness  at  having  achieved  something  new, 
but  also  a  feeling  of  disappointment  at  not  having 
made  a  better  performance.  There  was  no  mental 
fatigue  afterwards,  but  I  felt  conscious  of  slight 
muscular  tiredness  in  both  upper  and  lower  limbs. 
Owing  to  bad  Aveather  intervening,  my  second  flight 
did  not  take  place  till  a  week  later.  Then  my 
sensations  before  going  up  were  anything  but  pleasant, 
but  once  in  the  air  these  completely  vanished  owing 
to  the  mind  being  fully  occupied  in  attention  to 
flying.     This  time  I  felt  much  more  confident  during 


the  flight  and  better  able  to  eontrol  the  machine. 
Instead  of  the  machine  flying  me  there  was  the  feehng 
that  I  was  flying  the  machine."  The  reahsation  of 
this  fact  in  the  air  changes  the  whole  mental  attitude 
towards  flying,  and  in  it  originates  the  awakening  of 
self-confidence  in  flying.  In  the  second  flight  no 
difliculties  were  encountered  and  a  good  landing 
was  made. 

"  In  reviewing  my  solo  experience  I  was  struck 
by  the  following  facts  : — 

{a)  That  by  receiving  little  or  no  intimation  until 
j\ist  before  going  up  I  had  no  time  to  be  troubled 
with  anxieties  and  apprehensions  or  the  mental 
turmoil  of  repressing  these. 

{b)  That  actually  during  the  flight  I  had  no  feelings 
of    fear. 

(c)  That  the  element  of  fear  was  present  but 

(d)  That  if  there  is  a  long  interval  between  the 
intimation  and  the  actual  flight  then  actual  signs 
and  symptoms  of  fear  may  occur. 

(e)  That  there  is  a  fair  expenditure  of  mental  and 
bodily  energy  during  a  first  solo  flight. 

(/)  That  stimuli  may  be  sent  up  to  the  brain  in 
rapid  succession,  so  much  so  that  I  venture  to  think 
in  some  cases  a  state  of  mental  inertia  supervenes, 
and  may  possibly  account  for  a  proportion  of  crashes 
on  the  first  few  solo  flights." 

A  series  of  questions  was  drawn  up  relating  to 
these  points  amongst  others.  Each  pupil  immediately 
he  finished  his  first  solo  was  asked  to  fill  up  one  of 
these  forms  under  the  author's  guidance.  It  is 
important  that  tliis  should  be  done  almost  immed- 
iately after  the  flight  as  delay  alters  one's  impressions 
considerably.  At  first  the  author  made  pupils  write 
out  their  confessions  in  letter  form,  but  found  they 
often   strayed   from  the   real   issues  required.     If   a 


set  series  of  questions  has  to  be  answered  the  investi- 
gation is  rendered  more  simple  and  accurate.  Again, 
it  is  of  importance  that  the  questions  should  be  filled 
in  under  personal  supervision.  The  following  is  a 
copy  of  the  form  he  used  for  investigating  the  points 
in  question  as  well  as  others  not  of  purely  psychologi- 
cal interest. 

1st  solo  experiences 

Name Age Rank 

Previous  Occupation 

1.  Previous  air  experiences. — 

2.  \Miy  flying  was  chosen.^ — 

3.  Time  on  dual  control  before  solo. — 

4.  Imaginative  or  not. — 

5.  Proficiency  in  sports,  if  any. — 

6.  Estimate  of  one's  own  courage. — 

{a)  no  fear,  naturally  brave. 
(h)  ordinary     courage,     cautious,     fear     con- 
(c)  naturally  nervous. 

7.  Previous  health. — 

{a)  any  serious  disease,   e.g.,  hcai't,  lungs  or 

{b)  any  ear  or  eye  trouble. 
(c)  any  disease  of  nervous  system. 
{d)  liability  to  sea  or  train  sickness. 
(e)  ability  to  look  from  a  height  (not  flying), 

e.g.  from  cliffs,  tower,  etc.,  without  feeling 


8.  Family  history. — 

Any  evidence  of  disease  of  nervous   system,, 
e.g.,  fits,  epilepsy,  etc. 

9.  Medical  examination. — 

10.  Instructor's  report. 

11.  Later  progress. 



Entry  from  log  book. 

Time  after  intimation  of  having  to  do  first  solo. 

Sensations  before  going  up  : — 

(a)  Quite  confident. 

(b)  A  little  uncertain. 

(c)  Uneasiness  in  knees. 

(d)  Trembling   or  abdominal  sensations. 
In  describing  solo,  state  course. 

Line  of  direction,  and  did  you  keep  this  line  in 
getting  off  ? 

The  "  get  off  the  ground"  and  any  error  in  doing  so. 

In  the  air,  was  the  mind  occupied  all  the  time  in 
attention  to  flying,  watching  controls,  instruments, 
etc.  ? 

Or  did  the  element  of  fear  come  in  ? 

Or  was  fear  only  at  the  back  of  the  head  ?  (sub- 

Did  actual  fear  assert  itself  at  any  particular  moment 
of  flying,  e.g.,  in  "  bumps,"  turning,  coming  down, 
or  flattening  out  to  land — or  in  errors  of  flying, 
such  as  stalling,  nose  too  far  down,  too  much 
bank,  flying  on  uneven  keel,  inability  to  steer  a 
straight  course  ? 

Did  you  lose  your  head  at  any  time  and  in  what 
manner  ? 

Describe  the  coming  down  and  the  landing  :  any 
errors  ? 

Do  you  honestly  think  the  attention  of  the  mind 
is  so  taken  up  in  watching  controls,  instruments, 
etc.,  during  tlie  first  solo  that  fear  can  rarely 
assert  itself  ? 

Do  you  think  that  the  mind  (brain  attention)  can 
become  so  tired  on  a  first  solo  that  the  pilot 
would  give  up — his  attention  power  being  finished 
— and  let  the  machine  do  as  it  liked  ? 

Any  further  description  and  remarks. 



As  each  pupil  completed  his  first  solo  flight  he 
Avas  sent  immediately  to  the  author  and  under 
personal  supervision  each  filled  in  the  above  form. 
An  analysis  of  100  of  these  shows  some  facts  of  psycho- 
logical interest. 

{a)  Age  : 

The  average  age  was  21 J  years,  the  youngest  19 
and  the  oldest  34.  Undoubtedly  youth  with  all 
its  elasticity  is  best  suited  for  flying  and  more 
especially  for  war  flying.  As  far  as  school  flying 
•goes  a  man  between  30  and  40  years  of  age  can  learn 
to  fly  just  as  well  as  one  between  18  and  20.  The 
veteran  Cody  learnt  to  fly  when  47.  But  after 
30  years  of  age  the  strain  of  war  flying  is  in  most 
cases  too  much  to  withstand,  at  any  rate  for  long. 
Of  course  much  depends  on  the  physiological  age. 
Personally  the  author  thinks  24  to  26  the  best  age, 
as  then  the  judgment  is  more  mature  for  actual  flying, 
for  tactical  flying,  and  for  the  employment  of  aerial 

(6)  Previous  Occupation  : — 

As  the  majority  were  youthful  previous  occupa- 
tion proved  of  little  importance.  These  ranged  from 
student  to  diamond  merchant,  from  bank  clerk  to 

(c)  Motive  for  taking  ujy  flying  : — 
This  has  already  been  discussed. 

{d)  Imagination  : — 

64  confessed  to  have  imagination,  whilst  36  con- 
fessed to  have  little  or  none.  The  author  is  inclined 
to  thiak  that  those  with  marked  powers  of  imagina- 
tion may  make  the  more  skilful  pilots  as  far  as 
actually  handling  a  machine  goes,  but  those  with 
little  or  no  imagination  make  the  better  fighting 
pilots.  Much  depends  on  the  will  power  to  keep 
imagination  from  running  riot. 


(e)  Estimate  of  one'' s  own  courage  : — 

None  confessed  to  being  without  fear. 

Ninety-seven  said  they  had  ordinary  courage, 
were  cautious  and  could  control  fear. 

Three  said  they  were  naturally  nervous  but  could 
control  fear  and  keep  a  grip  on  themselves. 

None  confessed  to  being  actually  of  a  nervous 

(/)  Liability  to  sea  sickness  or  train  sickness  : — 

37  confessed  to  being  subject  to  this  whilst  63 
said  this  did  not  inconvenience  them. 

The  rolling  and  pitching  of  an  aeroplane  in  gusty 
weather  may  produce  a  feeling  of  nausea,  but  actual 
vomiting  rarely  takes  place  in  the  air.  But  in  some 
pupils,  especially  after  a  bumpy  cross  country  flight, 
actual  vomiting  may  occur  after  landing.  Again 
some  otherwise  quite  good  pilots  are  unable  to 
stand  aerobatics  on  this  account. 

(g)  Ability  to  look  from  a  height  without  feeling 
giddy  :— 
An  enquiry  into  this  elicited  the  fact  that  60  were 
able  to  withstand  looking  from  heights  stich  as 
cliffs,  towers,  etc.,  while  40  confessed  to  vertigo  or 
unpleasant  sensations. 

{h)  Interval  of  time  after  intimation  oj  having  to  go 
solo  : — 
This  varied  from  a  few  seconds  up  to  a  week. 
From  his  own  experience,  the  author  feels  convinced 
that  it  is  better  not  to  warn  the  pupil  till  the  last 
minute  that  he  has  to  go  up  alone.  Then  he  has 
no  time  for  appreliensions.  If  he  has  already  been 
flying  witli  liis  instructor  and  the  latter  gets  out 
and  tells  his  charge  to  go  on  alone,  the  pupil's  "  blood 
is  usually  up,"  and  he  takes  off  in  a  much  better 
frame  of  mind.  This  is  a  point  of  extreme  practical 
value  and  in  discussing  it  with  a  great  many  pupils 


and  instructors,  the  majority  heartily  agreed  with 

the  author. 

(i)  Sensations  before  going  up  : — 

The  extent  of  tliese  depends  very  much  on  the  time 
the  pupil  has  to  think  over  it.  Most  are  anxious  to 
get  it  over.  After  all  it  is  probably  the  most  momen- 
tous event  of  all  in  a  flying  man's  career. 

Seventy  felt  quite  confident. 

Thirty  felt  a  little  uncertain  as  to  their  ability  to 
do  it  successfully.  And  of  these,  3  had  a  feeling  of 
vmeasiness  in  the  lower  limbs,  whilst  8  had  abdominal 

(j)  In  the  air  w^as  the  mind  occupied  all  the  time 
in  attention  to  flying,  watching  controls,  instru- 
ments,   etc.  ? 

To  this  question  80  answered  yes,  whilst  20  said 
that  during  the  flight  they  had  time  to  think  of 
other  things  not  actually  connected  with  flying. 

(k)  Did  the  element  of  fear  come  in  during  the 
first  solo  flight  ? 

To  this  86  replied  no,  whilst  14  said  they  actually 
felt  afraid  in  the  air,  not  all  the  time,  but  at  certain 
moments  when  they  were  conscious  of  having  com- 
mitted  errors  in  flying. 

There  is  no  doubt  the  mental  concentration  is  so 
great  during  the  first  few^  solo  flights  that  there  is 
little  time  for  fear  to  assert  itself. 

(I)  Or  was  fear  only  at  the  back  of  the  head  (sub- 
conscious) ?  37  confessed  to  this,  whilst  63  said 
they  were  not  aware  of  this  condition  at  all. 

(m)  Did  you  lose  your  head  at  any  time  and  in 
what  manner  ?  97  gave  a  negative  answer  whilst 
3  confessed  to  momentary  loss  of  head.  Of  those 
three,  two  said  that  during  the  flight  they  momen- 
tarily forgot  how  the  controls  acted  and  committed 
errors  of  flying,  in  putting  on  opposite  bank  to  the 
rudder    action.     There    was    a    temporary    block    in 


the  new  and  complex  co-ordinated  response  requisite 
for  flying.  Happily  in  both  cases  the  loss  of  head 
was  only  momentary  and  the  errors  were  corrected 
in  time. 

The  third  case  confessed  that  in  gliding  down  to 
land  he  stalled  and  commenced  to  side-slip.  He 
writes  :  "  I  can  remember  instinctively  stretching 
out  my  left  liand  to  try  to  right  the  machine  by 
grabbing  something  outside  the  nacelle  (he  caught 
hold  of  a  strut).  Then  I  thought  to  myself,  "  You 
damned  fool,  you're  losing  your  head  and  will 
crash  if  you  don't  do  something."  I  seemed  to  regain 
my  self-control  and  opened  the  throttle,  at  the  same 
time  keeping  the  nose  down  a  little,  and  pushing  the 
control  to  port.  The  machine  came  back  to  her 
normal  level  and  I  went  off  again  on  another  circuit." 

{n)  Do  you  honestly  think  that  the  attention  of 
tlie  mind  is  so  taken  up  in  watching  instruments, 
controls,  etc.,  during  the  first  solo  that  fear  can 
rarely  assert  itself  ?  76  said  they  were  convinced 
this  was  so,  whilst  24  replied  that  they  thought  the 
attention  was  not  so  taken  up,  and  that  it  was 
possible   during  the   flight  to  become  really   afraid. 

(c)  Do  you  think  that  the  mind  can  become  so 
tired  on  a  first  solo,  that  you  might  have  to  give  up, 
and  let  the  machine  do  as  it  liked  ? 

.34  said  yes  to  this  and  66  said  no.  There  is  no 
doubt  that  the  first  solo  flight  is  a  great  strain 
on  the  nervous  system.  There  is  the  varying  stage 
of  excitement  before  the  flight  and  the  great  mental 
concentration  during  the  flight. 

If  many  errors  of  flying  or  difficulties  are  encoun- 
tered, and  es^pecially  if  the  first  solo  flight  be  of  long 
duration  then  tlie  repeated  stimuli  in  rapid  succession 
to  the  higlier  centres  produce  dilemma  and  mental 
inertia.  In  this  state  the  pupil  is  not  affected  by 
panic  but  simply  is  unable  to  do  anything  and  the 


machine  may  get  into  a  position  from  which  it 
cannot  be  recovered. 

It  is  wise  therefore  to  make  first  solo  flights  of 
short  duration. 

A  few  may  give  in  after  the  first  two  or  three  solo 
flights,  but  the  majority  rapidly  gain  confidence, 
and  soon  make  rapid  progiTss.  Some  are  apt  to 
grow  over-confident  and  a  little  careless — especially 
about  the  seventh  solo  flight,  and  here  a  word  of 
caution  from  the  instructor  may  be  necessary. 

After  about  30  hours  of  solo  flying  the  pupil 
becomes  a  qualified  aviator  and  gains  his  "  Wings." 
He  is  then  selected  according  to  his  ability  or  fitness 
for  one  or  other  special  set  of  flying  duties,  trained 
accordingly,  and  is  then  ready  for  war  flying. 

From  the  study  of  the  passenger,  dual  instructional, 
and  early  solo  flights  the  following  is  the  summary  of 
conclusions  of  practical  value. 

That  the  pupil  need  not  fear  height  giddiness, 
the  sensation  of  speed,  loneliness,  air  sickness,  or 
breakage  in  the  air.  That  instructional  flights  should 
not  be  of  long  duration  so  as  not  to  induce  mental 
fatigue  and  the  loss  of  knowledge  gained  in  the 
early  part  of  the  flight.  Nor  should  first  solo  flights 
be  of  long  duration,  in  case  dilenmia  and  mental 
inertia  should  supervene. 

That  everything  should  be  done  to  instil  con- 
fidence in  the  pupil. 

That  after  the  intimation  that  the  pupil  is  to  go 
on  his  first  solo,  the  time  should  be  as  short  as  possible 
before  the  actual  flight.  It  is  better  "  sprung  "  on 
him  s^lddenly.  That  it  is  comforting  to  know  that 
fear  in  the  air  rarely  occurs  on  the  first  few  solo 

In  his  progress  towards  qualification  the  aviator 
adapts  himself  to  a  new  set  of  co-ordinated  move- 
ments  in    response    to    stimuli    in    the    aeroplane's 


control.  He  acquires  air  experience,  develops 
"  hands,"  and  so  flying  becomes  more  or  less  auto- 
matic. A  few  never  get  beyond  the  pupil  stage 
and  flying  to  them  is  always  more  or  less  an  effort — ■ 
others  again,  although  slow  and  not  very  promising, 
as  pupils  suddenly  take  a  turn,  make  rapid  progress, 
and  prove  splendid  pilots  in  the  end. 

Rippon  has  shown  that  the  married  man  is  slower 
to  learn  and  does  not  prove  such  a  capable  pilot, 
at  least  for  war  piu'poses,  as  the  unmarried. 

(3)  From  the  point  of  view  of  the  Qualified  Aviator  : — ■ 

111  tlie  earlier  days  of  the  war  the  overseas  aviator 
was  called  upon  to  do  any  odd  job  in  aviation  for 
military  purposes.  Nowadays  naval  and  military 
aviation  is  divided  into  various  special  sections, 
each  requiring  different  types  of  aeroplanes,  and  to  a 
certain  extent  different  types  of  aviators. 

Depending  on  liis  flying  ability,  his  perfection  in 
aerial  gunnery,  his  physical  fitness  and  tempera- 
ment, he  is  chosen  for  one  of  the  following  special 
aviation  duties  :■ — 

(a)  Scout  Pilot  : — for  offensive  or  defensive  patrol, 
for  trench  strafing,  or  for  special  roving 

[h)  Artillery   Observation   Pilot. 

(c)  Reconnaissance    or    Photography    Pilot. 

{d)  Night   Bombing  Pilot. 

{e)  Day  Bombing  Pilot. 

(/)  Instructor    Pilot. 

[g)  Ferry    Pilot. 

{h)  Test  {uid  Experimental  Pilot. 

(?)   Seaplane  Pilot. 

All  are  subject  to  the  stress  of  flying  but  the  first 
live  liave  the  added  strain  of  enduring  anti-aircraft 
fire   from   the   ground,   and   attack  in  the   air  from 


hostile  machines.  Engine  faikire  may  be  disastrous 
enough  in  testing,  ferrying,  or  instructing,  but  it  is 
a  thousand  times  more  so  over  enemy  hues.  Fire 
in  the  air  is  a  constant  dread  in  aerial  warfare — 
while  another  factor  inducing  mental  strain  is  the 
danger  from  fog  and  loss  of  direction. 

{a)  The  Scout  Pilot,  from  the  very  nature  of  his 
calling  in  being  mostly  on  the  offensive,  and  from  the 
fame  derived  from  bringing  down  enemy  machines, 
is  the  one  most  often  in  the  limelight.  He  must  have 
the  physique  to  withstand  the  effects  of  high  altitude, 
and  also  of  sudden  and  rapid  change  of  heights. 
Called  upon  in  most  aerial  duels  to  perform  all 
sorts  of  aerobatics  he  must  possess  "  fine  hands," 
be  adept  in  flying  tactical  manoeuvres,  and  above 
all  an  expert  in  aerial  gunnery  and  a  deadly  shot. 
If  a  formation  leader,  he  has  to  make  rapid  but 
accurate  decisions,  otherwise  he  may  lead  not  only 
himself  but  perhaps  his  wliole  formation  to  destruc- 
tion. Temperamentally  he  is  better  with  no  imagina- 
tion, or  with  one  well  under  control.  He  is  more 
apt  than  anyone  to  suffer  from  a  feeling  of  loneliness, 
and  often  welcomes  a  fight  to  prevent  distraction. 
Happily  in  an  aerial  combat  he  has  full  mental 
occupation  in  jockeying  for  position,  and  only  later 
perhaps  when  he  is  safely  home  does  he  realise  the 
danger  he  had  come  through.  In  an  aerial  "  dog 
fight  "  there  is  always  the  danger  of  collision.  In 
the  days  before  formation  flying  and  aerial  melees 
were  common  the  scout  pilot  often  met  his  opponent 
alone.  The  thrill  of  danger  often  obsesses  him 
momentarily  before  giving  battle.  Experience  in 
air  fighting  gives  birth  to  a  new  flying  confidence. 
At  first  through  eagerness  he  may  open  fire  at  too 
long  a  range.  Later  he  learns  to  sum  up  his  opponent 
before  the  duel  commences.  If  he  finds  the  latter 
opening  fire  at  a  long  range  he  is  comforted  in  the 


fact  that  he  is  up  against  a  beginner,  or  one  who 
has  tlie  "  wind  up." 

Many  combats  in  tlic  air  are  indecisive.  In  the 
mental  tension  of  disappointment,  rage  often  seizes 
him  at  his  adversary's  escape,  and  here  his  judgment 
may  be  clouded  for  the  moment  and  his  fit  of  temper 
lead  him  to  break  formation  or  make  him  fail  to 
notice  other  sources  of  danger.  The  sight  of  an 
enemy  machine  going  down  in  flames  rarely  un- 
nerves him,  he  finds  exultation  in  the  fact  that 
another  enemy  aeroplane  has  been  beaten,  but 
rarely  thinks  of  its  previously  living  occupants. 
Tlie  sight  of  a  comrade  going  dow^n  may  unnerve 
him  but  it  often  spurs  him  on  to  revenge.  The 
author  has  been  struck  by  the  fact  that  our  most 
successful  aerial  fighters  are  all  very  clear  thinking- 
men.  They  all  recognise  the  super-importance  of 
accurate  aim  and  all  pay  special  attention  to  develop- 
ing this  by  constant  target  practice.  Again  most  of 
them  figure  out  all  the  chances  in  an  aerial  fight  and 
act  accordingly.  Ill  luck  has  always  to  be  reckoned 
with,  and  the  probable  extinguishing  of  a  meteoric 

The  successful  aerial  fighter  tries  to  approach  his 
opponent  rapidly  and  without  being  seen,  and  does 
not  open  fire  till  he  is  fairly  near.  Then  his  opponent, 
quite  unconscious  of  danger,  may  meet  instant 
death  from  an  unseen  hand. 

Many  scouts  prefer  this  diving  method  of  attack, 
and  should  they  fail  in  the  first  attempt,  clear  off 
rapidly,  gain  height  again  and  await  another  unsus- 
pecting  prey. 

{b)  The  artillery  observation  pilot's  duties  impose 
a  great  deal  of  nerve  strain  on  him,  and  lie,  more 
than  any  other  pilot,  is  apt  to  become  too  intro- 
spective whilst  in  the  air.  His  work  never  takes 
him    to   a   very   great   heiglit    and   he    is   constantly 


under  more  or  less  accurate  anti-aircraft  fire,  and  at 
times  subject  to  aerial  attack  by  hostile  scouts. 
He  has  always  an  observer  with  liim  and  thus  wards 
off  feelings  of  loneliness.  Confidence  in  each  other 
is  a  factor  of  supreme  psychological  importance. 
The  very  fact  that  they  can  speak  to  each  other  by 
telephone,  or  exchange  notes  or  even  a  smile,  un- 
consciously softens  the  nerve  strain.  His  work  may 
be  of  two  kinds.  If  on  an  artillery  observation 
patrol  he  has  to  fly  up  and  down  a  certain  stretch 
for  a  given  time  looking  for  enemy  gun  flashes. 
On  some  days  there  may  be  little  to  note  and  the 
work  becomes  deadly  monotonous,  especially  as  he 
is  all  the  time  a  moving  targ'et  for  "  Archie."  If  a 
beginner  he  may  become  at  first  horribly  afraid,  and 
unless  possessed  of  a  strong  will  is  much  tempted 
to  kick  the  rudder  bar  over  and  make  for  home. 
The  natural  response  to  fear  is  flight,  and  with  the 
means  so  ready  at  hand  it  is  a  wonder  thit  the 
animal  instinct  does  not  more  often  assert  itself. 
But  again  there  is  another  response  or  lack  of  it  to 
fear.  This  depends  on  the  subject's  temperament 
and  also  on  the  intensity  of  the  stimuli  producing 
fear.  Instead  of  the  flight  response  there  occur 
dilemma  and  mental  inertia  for  the  time.  His  other 
work  consists  of  doing  counter-battery  shoots,  i.e., 
ranging  a  friendly  battery's  fire  on  an  enemy  battery. 
Here  he  finds  more  mental  occupation  in  that  he  has 
to  locate  his  own  battery,  watch  for  ground  signals, 
get  out  his  wireless,  and  watch  for  and  correct  the 
fall  of  shot.  As  a  rule  the  work  is  not  of  such  long 
duration.  In  this  duty  he  is  not  nearly  so  apt  to 
become  introspective.  He  need  not  possess  the  flying 
ability  of  the  scout  pilot,  nevertheless  he  must 
possess  an  adequate  nervous  system. 

(c)  The  pilot  on  Reconnaissance  and  Photography 
has  to  fly  well  into  enemy  country.     He  carries  a 


companion  and  has  a  definite  mission.  He  may  be 
called  upon  to  defend  himself,  but  is  often  escorted 
by  a  fighting  scout.  His  dread  is  that  of  engine 
failure  over  enemy  country,  and  also  the  sudden 
onset  of  bad  weather.  He  may  hide  from  "  Archie  '* 
in  friendly  clouds  but  has  to  keep  a  sharp  outlook 
for  enemy  scouts. 

{d)  The  Night  Bombing  Pilot  in  his  training  period 
may  suffer  apprehensions  as  to  his  landings,  but 
once  accustomed  to  this  and  when  actually  on  night 
bombing  raids  he  rather  welcomes  the  friendly 
darkness.  Most  agree  that  it  is  the  least  nerve 
racking  work  of  all.  He  is  usually  blessed  with  a 
good  engine,  is  conscious  of  the  fact  he  can  see  and 
not  be  seen.  He  knows  that  "  Archie  "  is  more  or 
less  haphazard,  unless  perhaps  over  his  object, 
whilst  attack  from  the  air  is  mostly  a  matter  of  luck. 
He  knows  it  is  difficult  for  a  searchlight  to  pick 
him  up,  at  least  keep  on  him  for  any  length  of  time, 
and  he  derives  a  great  deal  of  glee  from  diving  on 
it  with  machine  gun  fire.  All  these  facts  give  him 
a  great  deal  of  comfort  and  one  finds  that  his  nervous 
system  does  not  give  way  easily. 

(e)  The  Day  Bomber  has  to  fly  in  formation  which 
he  must  rigorously  keep  or  else  disaster  will  befall 
him.  "Archie"  may  be  troublesome  at  times,  but 
dread  of  engine  failure  is  his  chief  worry.  He  is  as  a 
rule  escorted.  Formation  flying  is  the  great  salve 
to  his  feelings.  In  the  earlier  days  when  day  bomb- 
ing was  more  or  less  haphazard,  then  many  a  one, 
just  before  facing  the  barrage  over  a  town,  was  nuich 
tempted  to  release  his  bombs  anywhere  and  make 
back  for  safety.  Aerial  mob  psychology  plays  a 
great  part  now-a-days  in  the  complete  execution  of  a 
dayliglit  l)oni})ing  raid. 

(/)  The  Instructor  Pilot  has  not  the  nerve  strain 
of  flying  under  war  conditions  but  nevertheless  the 


responsibilities  of  his  work  are  very  great.  He  lias 
to  face  long  hours,  and  in  good  weather  may  be  doing 
six  hours  a  day  in  the  air.  He  must  be  both  physi- 
cally and  temperamentally  strong.  Besides  possessing 
flying  ability  he  must  have  the  power  to  impart  it  to 
others.  He  has  to  be  continuously  studying  his 
pupils  from  the  psychological  point  of  view,  ever 
keeping  in  mi  ad  the  supreme  importance  of  the 
psychic  factor  of  inspiring  confidence  in  others. 
He  must  have  the  patience  of  a  saint  aad  keep  an 
unruffled  temper.  He  has  always  to  face  the 
possibility  of  a  pupil  doing  something  extraordinarily 
stupid  in  the  air — an  error  at  an  insufficient  height 
to  prevent  disaster.  This  could  certainly  be  obviated 
by  equipping  all  instructional  machines  with  a  means 
of  rapidly  rendering  neutral  the  pupils'  controls. 

How  great  is  the  strain  on  the  instructor  of  sending 
off  pupils  on  their  first  solo  flights  can  only  be  realised 
by  those  with  long  experience  of  flying  school  life. 
His  judgment  as  to  when  his  charge  is  ready  to  fly 
alone  must  be  fine  to  a  degree.  The  responsibility 
of  a  life  often  rests  on  his  shoulders.  The  author  has 
been  repeatedly  impressed  by  the  fact  that  most 
successful  instructors  are  men  of  unusually  strong 
physique.  It  is  a  mistake  to  send  good  instructors 
on  war  flying.  They  may  lose  the  glory,  excite- 
ment, and  rewards  connected  therewith,  but  it  is 
on  the  results  of  their  work  that  reliance  is  placed 
on  maintaining  a  supply  of  the  very  finest  aviators. 

On  the  other  hand  it  is  a  mistake  to  impose 
instructor's  duties  on  the  pilot  from  overseas — by  way 
of  giving  him  a  rest.  Let  him  have  his  rest  in  a 
proper  manner.  He  may  be  getting  stale,  easily 
made  irritable,  and  not  at  all  interested  in  instructing. 
To  make  him  do  so  is  to  court  disaster. 

ig)  The  Ferry  Pilot's  life  is  probably  the  easiest 
of  all.     There  is  little  nerve  strain,   and  this  is  an 


excellent  way,  for  those  who  wish  it,  of  giving  over- 
seas pilots  a  rest,  and  yet  maintaining  their  interest 
in  aviation. 

{h)  The  Test  and  Experimental  Pilot  must  possess 
the  requisite  "  hands  "  for  flying.  Sliould  appre- 
hensions arise  they  mainly  revolve  round  the  amount 
of  confidence  he  has  in  the  designer  and  constructor 
of  the  particular  machine  he  is  flying.  It  is  to  the 
good  if  he  is  of  a  mechanical  turn  of  mind  and  better 
still  if  he  so  acquaints  himself  with  the  details  of 
construction  and  design  as  to  consider  himself  an 
expert  in  these  matters. 

(?)  The  Seaplane  Pilot's  duties  expose  him  to  a 
peculiar  strain  not  found  in  other  aviation  duties. 
The  fact  that  he  has  to  carry  out  long  patrols  over 
the  sea,  with  perhaps  for  hoiu's  on  end  no  visible 
landmarks,  gives  him  much  time  for  reflection. 
He  is  apt  to  suffer  from  a  peculiar  sense  of  isolation 
and  ponder  over  the  thought  of  engine  failure,  a 
much  more  serious  occurrence  over  the  sea  than 
over  the  land.  As  one  seaplane  pilot  explained  it — 
"  If  you  have  a  forced  landing  even  in  the  desolate 
country  you  can  always  get  to  a  friendly  pvib  for 
the  night,  but  '  in  the  ditch  '  there  are  no  pubs." 
Again  sliould  he  have  a  forced  landing  and  the  sea 
become  at  all  unsettled  he  has  to  face  the  worst 
form  of  sea-sickness  known. 

In  the  psychological  study  of  the  aviator  one  is 
struck  by  the  importance  of  the  motive  in  taking 
up  aviation.  This  gives  more  or  less  driving  power 
to  the  conscious  endeavour  to  overcome  the  obstacles 
in  learning  to  fly— and  supplies  the  determination  to 
surmount  difTieultics  throughout  the  whole  flying 
career.  Tlie  author  places  determination,  grit, 
*'  guts,"  call  it  what  you  may,  as  the  most  important 
factor  in  flying. 

At  the  commenecmcnt  of  tlic  flvinii  career  atten- 


tion  is  called  into  play  and  kept  fully  occupied  in 
the  acquisition  of  responding  to  new  stimuli  with 
a  new  series  of  muscular  contractions  in  correct 
proportion  and  sequence.  At  the  outset  execution 
often  falls  short  of  intention.  Some  of  the  motor 
responses  are  excessive  or  superfluous,  others  are 
omitted  at  the  proper  time  or  in  proper  sequence 
and  disturbing  factors  arise. 

In  attaining  progress  and  success  the  proper  control 
is  gradually  gained  over  the  requisite  muscular 
responses.  Attention  is  fixed  on  what  alone  is 
necessary.  This  is  retained  and  the  rest  forgotten. 
When  this  control  is  thoroughly  organised  then 
conscious  effort  is  no  longer  necessary  and  flying 
becomes  automatic. 

Perception,  Discrimination,  and  Retentiveness  are 
important  factors  in  learning  to  fly.  When  flying 
becomes  more  or  less  automatic  then  arises  the 
question  of  the  adaptability  of  the  aviator  to  parti- 
cular flying  duties.  The  law  of  survival  of  the  fittest 
as  a  rule  answers  this  question,  but  the  psychologist 
and  physiologist  may  supply  a  more  economical 

A  great  deal  of  practical  psychology  has  been 
carried  out  in  connection  with  aviation,  especially 
with  regard  to  the  study  of  reaction  times  and 
emotional  responses  ;  and  also  in  connection  with 
tests  of  the  attention,  behaviour,  and  motor  responses 
at  atmospheric  pressures  corresponding  to  high  alti- 

Loewy  and  Placzek  in  1914  reported  a  series  of 
tests  of  the  attention  and  other  psychic  phenomena 
on  themselves,  and  two  others,  in  a  cabinet  with 
an  atmospheric  corresponding  to  that  of  an  alti- 
tude of  4,000  metres.  Objective  findings  w^ere  com- 
paratively slight  although  mistakes  in  additions 
were  more  frequent  the  more  rarefied  the  air.     The 


sensation  of  being  incapable  of  giving  close  attention, 
of  being  unable  to  act  promptly  and  with  precision, 
these  subjective  factors  were  prominent,  and  exerted 
a  certain  amount  of  paralysing  effect.  The  subjects 
were  quiet,  warm,  and  free  from  responsibility — 
and  therefore  were  not  exactly  under  the  conditions 
as  in  actual  flight. 

In  America  similar  but  more  elaborate  tests  have 
been  carried  out.  One  would  suggest  that  similar 
tests  should  be  done  under  the  effects  of  cold — a  most 
important  factor  at  altitudes. 

Psychological  investigation  helps  considerably  in 
determining  deterioration  or  staleness  in  the  aviator. 
The  latter  may  be  fit  for  a  particular  flying  duty  or 
even  flying  in  general  but  the  question  arises  how 
long  can  he  remain  fit. 

Unhappiness  in  the  air,  introspection,  morbid 
thoughts,  and  the  feeling  that  the  dangers  connected 
with  flying  are  developing  into  an  obsession,  are 
danger  signals  that  the  psychologist  alone  can 
discern  and  can  take  action  accordingly. 

This  leads  us  to  the  domains  of  mental  pathology, 
and  the  study  of  the  various  nervous  breakdowns 
occasioned  by  the  stress  of  flying. 


The  Aero-Neuroses 

The  term,  The  Aero-Neuroses,  is  used  by  the  author 
to  cover  the  various  types  of  nervous  breakdown 
that  may  arise  in  those  engaged  in  flying.  Fleet 
Surgeon  H.  V.  AVells,  R.N.,  coined  the  word  "  Aeros- 
thenia,"  to  designate  these  conditions,  but  this 
word,  although  euphonious,  is  altogether  incorrect. 
Various  other  terms  have  been  used,  such  as  Flying 
Stress,  Flying  Sickness  and  Aviators'  Neurasthenia, 
but  "  Aero-Neurosis  "  is  a  better  term  to  use,  includ- 
ing as  it  does  any  type  exhibiting  manifestations  of 
functional  disease  of  the  nervous  system  brought  on 
by  flying.  The  subject  is  a  very  large  one,  and  one 
of  the  most  difficult  to  be  faced  by  the  medical 
officer,  as  more  cases  of  this  nature  than  of  any 
other  present  themselves  in  Air  Force  work.  The 
questions  of  prevention,  diagnosis  and  treatment 
are  of  equal  importance  alike  to  the  aviator  himself 
and  to  the  service.  Nervous  breakdowns  have 
been  noted  since  the  early  days  of  flying  ;  in  fact 
they  may  be  classed  as  an  occupation  neurosis — 
a  comparatively  new  occupation,  namely  :  flying. 
Aero-neurotic  conditions  may  be  brought  on,  firstly, 
simply  by  the  strain  of  learning  to  fly.  Loss  of 
confidence  and  a  fear  of  going  up  in  the  air  arise, 
a  neurasthenic  condition  develops,  the  chief  char- 
acteristic of  which  is  one  of  the  phobias,  namely  : 
aero-phobia.  Again,  the  condition  may  follow  an 
aeroplane    accident    at    any    time    in    the    aviator's 



career  ;  it  is  commonly  of  a  more  severe  type  if 
induced  early  in  his  flying  life.  The  shock  of  the 
crash  alone  may  do  it,  or  it  may  follow  where  con- 
cussion supervenes,  or  where  bodily  injury  has  been 
sustained  in  a  flying  accident.  Finally,  neurasthenia 
may  follow  the  added  strain  of  war-time  flying  with 
its  attendant  long  flights,  great  altitudes,  night  flights, 
aerial  fighting,  and  anti-aircraft  fire.  It  is  an 
extremely  difficult  matter  to  say  beforehand  which 
individual  is  likely  to  break  down  in  flying.  Tem- 
perament is  very  difficult  to  estimate  clinically. 
More  rigorous  examination  in  admitting  candidates 
to  the  Air  Force  has  certainly  eliminated  a  number 
of  candidates  whose  nervous  systems  would  have 
been  likely  to  give  way.  No  tests  or  series  of  tests 
have  proved  of  much  value  in  picking  out  such 
individuals,  but  a  study  of  the  psychology  of  flying 
helps  gi'catly  in  estimating  the  temperament  of  the 
aviator.  Along  psychological  lines  will  be  found 
the  guide  to  eliminating  the  types  likely  to  break 
down  in  flying  ;  and  also  in  many  cases  the  means 
of  treating  such  cases.  The  aerodrome  medical 
officer  interested  in  flying  has  the  best  opportunity 
of  studying  the  various  Aero-Neuroses.  Given  such 
a  doctor  in  conjunction  with  an  experienced  senior 
flying  officer  or  instructor  we  have  a  powerful  com- 
bination at  an  air  station  for  speedily  eliminating  the 
nil  (it.  foi-  preventing  many  from  breaking  down,  for 
stopping  a  wave  of  Aero-Neurosis  amongst  others, 
for  reducing  a  number  of  preventable  flying  accidents 
and  thus  saving  both  personnel  and  material  for  the 
good  of  the  service.  Of  the  various  Aero-Neuroses 
the  most  common  are  those  with  either  neurastlienic 
syniptorjis  or  symptoms  i)ertaining  to  hysteria  ; 
but  one  Jiiid  all  of  the  various  manifestations  of 
functional  disease  of  the  nervous  system  may  be 
found.     Before  discussing  the  etiology  and  various 


clinical  types  that  are  met,  it  will  be  well,  from  the 
practical  point  of  view,  to  divide  these  cases  into 
tAvo  great  classes  : — (I.)  The  Aero-Neuroses  found 
among  pupils  from  the  commencement  of  their 
flying  career  up  to  the  time  when  they  become 
qualified  aviators,  roughly  after  about  thirty  hours' 
solo  flying.  And  (II.)  The  Aero-Neuroses  found 
among  qualified  aviators  and  for  the  most  part 
those  engaged  in  war  flying. 

Class  I.  the  author  will  deal  witli  himself  in  Section 
A  of  this  chapter,  whilst  Class  II.  in  Section  B  of  this 
chapter  has  been  written  by  his  friend  and  colleague, 
Surgeon  Oliver  H.  Gotch,  R.N.,  to  whom  he  is  greatly 
indebted.  During  the  past  year  Surgeon  Gotch  has 
had  under  his  care  a  large  number  of  flying  officers 
whose  nervous  systems  have  broken  down  under 
the  strain  of  war  flying.  His  investigations  into 
these  conditions  have  been  most  complete,  and 
from  an  independent  point  of  view  purely  as  a 
medical  officer  interested  in  flying,  the  author  is  in 
hearty  agreement  with  all  the  views  he  expresses. 



During  two  years  as  medical  officer  a,t  flying  schools 
about  600  pupils  passed  tlirough  the  author's  hands. 
They  arrived  in  small  batches  from  time  to  time,  and 
he  had  every  opportunity  of  getting  to  know  them 
and  watching  them  through  the  pupil  stage  of  their 
flying  career.  The  great  majority  went  on  to  qualify 
and  then  passed  out  to  other  schools  for  special 
training  or  else  on  to  war  squadrons.  About  10 
per  cent,  gave  up  or  were  made  to  give  up  owing  to 
some  type  of  Neurosis  supervening.  The  pupil 
may  come  to  consult  the  medical  officer  himself  or 


he  may  be  brouglit  by  his  instructor.  In  some  cases 
no  more  difficult  problem  can  face  the  aerodrome 
medical  officer.  Much  depends  on  the  opinion  he 
shall  form,  and  this  must  therefore  be  based  on  a 
careful  examination,  backed  by  experience  and  a 
sound  knowledge  of  what  is  required  of  the  aviator. 
Great  help  can  be  obtained  by  working  hand  in  hand 
with  the  instructors.  The  type  of  Neurosis  mostly 
found  in  pupils  is  of  the  neurasthenic  variety  but 
occasionally  the  hysterical  variety  is  found.  It 
is  of  importance  to  know  the  time  of  onset  of  the 
Neurosis.  It  may  occur  (a)  during  the  period  of 
dual  control  instruction  ;  {b)  more  commonly  during 
the  first  few  solo  flights  ;  (c)  less  commonly  later, 
Avhen  the  pupil  is  either  transferred  to  another 
flight  or  lias  to  fly  faster  types  of  aeroplanes ; 
(d)  again,  the  onset  often  dates  back  to  a  flying 
accident  either  without  injury  or  after  sustaining 
shock,  concussion,  or  bodily  injury,  (e)  Moreover, 
it  has  been  found  to  follow  where  the  pupil  has  not 
actually  been  in  a  flying  accident  but  has  been 
tlie  witness  of  one.  (f)  Finally  there  is  the  case 
following  a  crash,  usually  with  severe  bodily  injury, 
in  whieli.  very  late,  Aero-Neurosis  supervenes.  If 
the  pupil  develops  Aero-Neurosis,  and  it  remains 
undetected  he  may  infect  other  pupils  ;  sometimes 
quite  a  wave  develops,  one  pupil  who  has  given  up 
flying  being  followed  in  this  course  by  two  or  three 
more  in  the  same  week.  As  will  be  seen  later, 
prompt  measures  are  required  to  deal  with  the 
situation.  After  enquiring  into  the  time  of  onset, 
one  notes  from  the  clinical  point  of  view  whether  a 
case  is  of  the  neurasthenic  ov  hysterical  variety. 
Often  one  variety  merges  into  the  other.  All  symp- 
toms are  carefully  noted,  and  a  physical  examination 
carried  out,  but  the  latter,  in  pupils,  usually  returns 
negative  results.     What  are  the  usual  types  of  Aero- 


Neuroses  the  medical  officer  has  to  deal  with  ? 
Let  us  take  the  simplest  case  first  :  the  pupil  will 
come  along  to  consult  the  medical  officer — he  may 
or  may  not  have  had  a  minor  crash  and  escaped 
physical  injury,  but  he  Avill  say  honestly  that  he 
does  not  "want  to  continue  flying.  His  nervous 
system  is  not  strong  enough  to  bear  the  strain  of 
flying,  and  luckily  he  himself  recognises  it  and  is 
manly  enough  to  confess  it.  Such  a  pupil  one  has 
to  admire  for  his  moral  courage,  as  it  has  to  be 
remembered  that  pupils  are  very  sensitive  to 
their  fellow-pupils'  opinion.  The  treatment  is  easy  ; 
his  wislies  are  granted  and  he  is  detailed  to  another 
branch  of  the  service.  As  an  instance  of  such  a 
case,  the  author  has  had  a  pupil  come  to  him  for 
advice  after  having  done  only  one  hoiu-'s  dual  con- 
trol instruction.  This  pupil  said  that  honestly  he 
could  not  go  on  with  it.  Another  made  a  very 
erratic  first  solo,  landed  safely,  stepped  out  of  the 
machine  and  said  that  nothing  on  earth  would 
induce  him  ever  to  go  up  again.  Another  came 
after  having  done  four  solos,  and  another  after  five 
hours'  flying,  and  both  confessed  to  their  inability 
to  go  on  with  it.  The  next  type  of  case  is  one 
w^ho  comes  either  just  near  the  end  of  his  dual  control 
period  of  instruction,  or  perhaps  after  his  first  or 
second  solo  and  complains  of  headaches,  usually 
w^orse  after  flying,  and  as  a  rule  attended  by  gastric 
symptoms,  often  nausea,  but  no  actual  vomiting  ; 
or  perhaps  he  may  have  difficulty  in  getting  to  sleep, 
or  his  sleep  may  be  broken  or  fitful.  Dreams  con- 
nected or  not  with  aviation  may  be  reported.  In 
some  cases  the  chief  symptoms  may  be  giddiness 
in  the  air.  No  mention  as  a  rule  is  made  of  any 
distaste  for  flying,  the  mental  attitude  towards 
flying  is  studiously  avoided  in  the  history  given. 
Some    appropriate    treatment    is    ordered,    and    the 


pupil  is  placed  on  the  "  Excused  Flying  "  list.  In 
a  few  days,  sometimes  depending  on  the  state  of  the 
flying  weather,  he  will  reappear  with  the  story 
that  he  is  not  much  better  or  that  the  symptoms 
liave  recurred  ;  perhaps  there  may  be  some  new 
symptom  added,  and  usually  if  a  trial  fliglit  has  been 
undergone,  vertigo  is  complained  of.  A  consultation 
with  the  instructor  at  this  stage  will  throw  some 
light  on  the  subject.  Of  course  physical  examina- 
tion and  treatment  are  not  to  be  excluded  but 
much  can  be  gained  by  a  good  heart  to  heart  talk 
with  the  patient.  Some  confess  that  they  are  unhappy 
in  the  air  and  give  in  ;  others  stoutly  deny  that 
they  want  to  give  up  flying,  and  say  that  they 
would  very  much  like  to  carry  on  with  flying  if 
they  could  only  get  well  again  physically.  In 
these  latter  cases  the  medical  officer  may  have 
great  difficulty  in  deciding.  The  physical  signs 
are  few  or  absent ;  he  may  only  find  an  increased 
knee  jerk,  there  may  or  may  not  be  tremor,  and 
similarly  with  evidence  of  equilibration  instability. 
It  may  be  doubted  if  even  physiological  tests  would 
lielp  one  at  this  stage.  What  is  lacking  is  that  one 
has  not  the  instrument  for  probing  or  laying  bare 
the  subject's  temperament.  Sooner  or  later  the 
truth  comes  out,  and  these  cases  give  up  or  are  re- 
jected as  unfit  for  further  flying.  These  cases  are 
of  the  neurasthenic  variety,  and  the  chief  symptom, 
though  in  many  cases  denied,  is  aerophobia.  If 
they  go  on  undetected  great  harm  may  be  caused 
not  only  to  themselves,  in  that  they  become  unhappy, 
depressed,  shun  their  comrades  and  suffer  in  general 
health,  but  also  to  their  fellow-pupils,  some  of  whom 
may  become  changed  tliereby  in  their  mental 
attitude  towards  flying.  Another  class  of  case  of 
Aero-Neurosis  with  onset  similar  to  the  above, 
takes  on  the  character  of  hysteria.     Some  show  quite 


notable  signs  such  as  marked  tremor  of  limbs,  lips, 
etc.  Functional  paralysis,  contracture  or  a  hyper- 
aesthctic  condition  may. develop.  The  author  was 
called  in  consultation  to  a  case  lately  in  which  with 
no  history  of  injury  a  painful  contracture  of  the 
knee  was  present.  The  knee  was  kept  semi-flexed 
and  the  gentlest  touch  caused  excruciating  pain. 
There  was  a  glove  area  of  hyperaesthesia.  There 
was  no  fluid  in  the  joint,  no  extra-articular  swelling, 
no  redness  or  local  increase  of  temperature,  whilst 
X-Rays  showed  nothing  abnormal.  There  was  no 
evidence  of  tuberculosis  in  himself  or  family,  and 
no  history  of  gonorrhea  or  syphilis.  On  enquiry  it 
was  found  tliat  he  had  nearly  finished  his  dual 
control  period  of  instruction  and  would  soon  be 
ready  for  his  first  solo.  Under  pn  anaesthetic  the 
knee  relaxed.  This  was  undoubtedly  a  case  of 
hysterical  joint  and  the  cause  was  made  plain.  In 
another  case  complaint  was  made  of  excessive  tender- 
ness and  pain  over  the  middle  of  the  sacrum,  no 
evidence  of  organic  disease  was  found,  and  in  this 
case  on  searching  enquiry  there  waS' elicited  a  marked 
distaste  for  flying,  although  he  had  gone  as  far  as 
twenty  hours'  solo  flying.  It  is  rather  a  ticklish 
point  whether  to  turn  down  a  pupil  who  begins  to 
suffer  from  a  form  of  neurosis  and  who  has  done 
say,  twenty  to  thirty  hours'  flying.  So  far  as  his 
own  experience  goes  the  author  has  never  yet  found 
a  case  of  this  kind  do  well.  It  is  well  to  keep  in 
mind  always  the  question  of  malingering;  it  is  an 
undoubted  fact  that  some  individuals  are  admitted 
who  never  intend  to  fly  ;  and  others  discover  either 
that  they  have  no  liking  for  flying  or  that  they  are 
not  up  to  it  and  try  to  avoid  it  on  medical  excuses. 
In  the  earlier  days  these  individuals  on  one  or  other 
excuse  managed  to  spend  quite  a  time  in  the  service 
without   doing  much   flying.     They   often  tried  the 


doctor  with  symptoms  both  weird  and  varied,  but 
if  the  doctor  has  any  knowledge  of  flying  it  is  fairly 
easy  to  diagnose  these  cases  and  treat  them  accord- 

Now  one  turns  to  the  class  of  case  in  which  a 
Neurosis  follows  a  flying  accident.  In  these  a  morbid 
condition  follows  the  shock  of  the  crash,  and  may 
present  symptoms  of  neurasthenia  or  hysteria  or 
both.  The  condition  is  absolutely  the  same  as  the 
Traimuitic  Neurosis  knows  as  "  Railway  Spine  " 
or  a  "  Railway  Brain."  In  the  crash  the  pupil 
may  sustain  more  or  less  severe  bodily  injury — 
he  may  sustain  more  or  less  severe  concussion — lie 
may  receive  bodily  shock  without  apparently  physical 
injury,  or  finally  he  may  simply  be  affected  by  the 
profound  mental  impression  of  the  crash.  After 
one  or  all  of  these  conditions  the  Aero-Neurosis 
may  supervene.  As  in  an  accident  of  any  sort 
with  danger  to  life  one  rarely  feels  the  mental  side 
of  it  until  the  next  day,  or  perhaps  not  till  some 
time  later,  and  then  the  enormity  of  the  danger 
that  has  been  escaped  spreads  itself  before  one. 
Those  with  little  imagination  or  with  imagination 
well  luider  control  can  or  may  dismiss  the  whole 
prol)kni  from  the  mind  almost  inmiediately,  but  in 
others  less  fortunate,  the  picture  repeats  itself, 
becomes  more  and  more  developed  mentally  until 
it  finally  becomes  fixed.  Such  a  fixture  presents 
itself  as  a  temperamental  breakdown,  and  any  form 
of  Aero-Neurosis  may  develop.  For  example,  after 
a  crash  the  pupil  often,  if  apparently  unhiui:,  is 
now-a-days  excused  flying  for  a  day  or  two. 
Should  a  Neurosis  develop  he  will  probably  complain 
of  headache,  or  insomnia,  or  may  suffer  from  dreams 
in  which  flying  accidents  predominate.  Again  he 
may  exhibit  some  form  of  irritability  or  simply  com- 
j)lain   that   he    feels   out    of   sorts.     Should   he   have 


sustained  a  minor  injury,  such  as  a   bruise,  sprain, 
or  a  trifling  wound,  the  significance  of  such  will  be 
unduly    dwelt    on.     One    finds    that   the    symptoms 
do    not    decrease    with   the    physical    signs    of    such 
injuries.     After  appropriate  surgical  treatment  these 
cases  are  usually  sent  on  leave  for  a  week  or  two. 
Should   a  Neurosis   develop  the   pupil   on  returning 
to  duty  will  say  that  he  does  not  feel  fit  and  detail 
any  or  all  of  the  symptoms  described  above.     They 
often    complain    of    being  easily    fatigued,  with    in- 
ability  to   concentrate    on   reading,    study,    lectures 
or   games.     Some   confess  that   their   confidence   in 
flying  is  lost  whilst  others  stoutly  aver  the  opposite. 
Others  say  their  confidence  will  return   as  soon  as 
they  feel  all  right  again.     It  is  interesting  to  note 
that  after  a  crash,  usually  in  which  severe  physical 
injury  has  been  sustained,  Aero-Neurosis  may  super- 
vene as  a  late  development.     This  has  been  noted 
where  even  although  the  injuries  were  severe  there 
was  no  loss  of  consciousness.     After  such  a   flying 
accident  the  pupil  is  laid  up  for  weeks  or  perhaps 
months    under    surgical    treatment.     He    may    have 
been  very  keen  on  flying,  and  during  his  treatment 
and    convalescence    he    does    not    mind    much    his 
injuries,   but  rather  frets   over  the   fact  that  he   is 
losing  time  and  that  his  brother  pupils  are  forging 
ahead  of  him  in  flying.     But  later  on  the  details  of 
the  occiuTcnce  of  his  crash  begin  to  get  hold  of  him, 
and  a  kind  of  slow  mental  cancer  sets  in,   and  as 
time  goes  on  and  he  is  ready  to  return  to  duty  all 
keenness    on    flying    has    disappeared,    and    a    real 
traumatic  neurosis  has  developed.     For  example,  a 
pupil   on  his  second  solo  crashed,   was  thrown  out 
and  sustained  a  telescoping  fracture  of  his  seventh 
thoracic    vertebra    without    involvement    of    spinal 
cord  ;  there  was  no  loss  of  consciousness,  but  surgical 
shock  and  pain  were  very  severe.     For  two  months 


he  lay  in  a  special  spinal  frame  ;  his  daily  conversa- 
tion Avas  on  his  speedy  return  to  flying  and  how  he 
must  make  up  for  lost  time.  Convalescence  took 
another  tAvo  months,  and  then  all  keenness  for  flying 
had  gone.  Such  is  a  brief  description  of  the  types 
of  Aero-Neuroses  that  occur. 

Having  noted  the  time  of  onset  in  the  pupil's 
flying  career,  consulted  with  the  instructor,  carried 
out  as  far  as  possible  a  thorough  physical,  psycho- 
logical and  physiological  examination  and  diagnosed 
the  clinical  type  of  Aero-Neurosis,  the  aerodrome 
medical  officer  is  faced  with  the  problem  of  treat- 
ment. Earlier  in  this  chapter  a  division  was  made  of 
Aero-Neuroses  from  the  practical  point  of  view 
into  two  classes,  namely  :  (1)  among  pupils,  and 
(2)  among  qualified  pilots  and  those  engaged  in 
(hiily  flying  or  war-time  flying.  The  importance 
of  this  distinction  from  the  point  of  view  of  treat- 
ment will  be  seen  below.  In  the  early  days  of  flying 
before  there  was  much  medical  interest  in  or  super- 
vision over  flying,  if  a  pupil  crashed  and  was  appar- 
ently uninjured,  he  was  ordered  to  go  up  again  in 
another  machine  almost  immediately.  This  was 
supposed  to  prevent  loss  of  nerve  or  if  momentarily 
lost  by  the  crash  to  facilitate  the  immediate  recovery 
of  it.  The  author  has  seen  the  results  of  this  method 
of  treatment,  and  can  say  emphatically  it  is  a 
method  to  be  condemned  ;  he  is  sure  that  most 
experienced  instructors  will  agree  with  him  in  this. 
Bullying  treatment  with  pupils  never  pays  in  a 
flying  seliool.  It  must  be  remembered  that  pupils 
are  usually  young,  some  having  practically  just 
left  school.  A  nervous  breakdown  sets  in  early  in 
their  career  and  some  must  go  through  a  terrible 
mental  struggle  between  giving  up  or  going  on 
witli  flying  ;  and,  therefore,  a  great  deal  of  firm 
sympathy  is  required.     Some  are  afraid  to  confess 


to  their  instructor,  and,  therefore,  if  they  receive 
friendly  help  and  advice  from  the  doctor  a  great 
deal  of  their  mental  anxiety  is  relieved.  The  very 
fact  that  they  can  unburden  their  troubles  to  some 
one  relieves  them  considerably.  Symptomatic  treat- 
ment must  be  carried  out,  e.g.,  headaches  must 
be  treated,  and  for  this  the  author  usually  prescribes 

Ammon.  Bromide       gr.  xx. 
Phenacetin  gr.  viii. 

Caffein  Citrate  gr.  ii. 

This  will  relieve  most  ordinary  headaches  and  should 
the  pupil  report  no  relief  from  this  powder  then  one 
suspects  malingering.  Gastro-intestinal  disturbance 
must  receive  appropriate  dietetic  and  medicinal 
treatment.  One  rarely  finds  evidence  of  organic 
disease  in  pupils,  at  least  now-a-days  with  the 
rigorous  methods  employed  before  the  candidate  is 
admitted  to  the  Air  Force.  Most  of  the  pupils  who 
give  up  or  are  turned  down  from  flying  should  be 
re-examined  as  for  admittance  to  the  Air  Force. 
In  the  majority  of  these  so  dealt  with  little  evidence 
of  vaso-motor  disturbance  or  equilibration  instability 
was  detected.  About  ten  per  cent,  give  up  or  are 
rejected.  In  treating  these  from  the  point  of  view 
of  flying,  the  author  at  first  worked  in  the  dark  and 
had  gradually  to  feel  his  way.  Some  were  simply 
excused  flying  for  a  day  or  two,  and  were  given 
ground  duties,  and  some  were  given  short  leave, 
perhaps  a  week-end  or  up  to  a  week.  The  results 
were  unsatisfactory,  for  no  sooner  were  they  back 
to  flying  than  symptoms  reappeared.  Some  were 
put  back  on  dual  control  instruction  again,  the 
"  Slow  Recovery  "  method  mentioned  by  Wells, 
whilst  others  were  turned  over  to  another  instructor. 
But  the  results  were  no  better.  Some  who  had 
sustained  minor  injuries  in  a  crash  were  given  from 


fourteen  days  to  two  months'  leave  away  from  every- 
thing conneeted  witli  flying,  but  even  this  did  not 
restore  their  flying  eonfidenee.  As  an  example,  a 
pupil  on  his  second  solo  made  a  bad  take  off  the 
ground,  lost  his  head  and  crashed.  The  machine 
turned  over,  and  the  pupil  sustained  a  fracture  of 
the  nose  with  very  slight  displacement  aud  a  few 
minor  bruises.  He  was  in  hospital  two  weeks,  and 
was  tlien  given  a  week's  leave,  but  on  return  to  duty 
he  said  lu'  did  not  feel  quite  fit  to  resume  flying, 
but  thought  that  later  his  confidence  would  return. 
He  was  a  keen  engineer,  and  well  up  and  interested  in 
all  connected  with  engines.  As  an  experiment  per- 
mission was  obtained  for  him  to  go  on  three  months' 
leave  to  his  own  home  and  to  avoid  all  connec- 
tion with  flying.  He  was  forbidden  to  read  flying 
papers,  discuss  flying  subjects,  or  mix  with  any  other 
flying  officers.  On  his  return  he  looked  physically  fit 
and  well,  but  on  examination  he  said  his  mental 
attitude  to  flj'ing  had  not  changed  since  his  crash, 
and  that  his  "  nerves  "  did  not  feel  up  to  it.  Similar 
results  were  obtained  with  several  other  cases. 
After  trying  the  various  methods  detailed  above 
no  good  results  were  obtained,  and  as  it  was  noticed 
that  one  case  of  Aero-Neurosis  might  affect  others 
one  was  forced  from  the  point  of  view  of  value 
to  the  service,  to  look  upon  the  infective  side  of 
the  condition,  and  prevent  that  at  all  costs.  The 
conclusion  come  to,  which  was  supported  by  the 
CO.,  the  senior  flying  officer  and  all  instructors 
alike  was,  that  as  soon  as  a  pupil  shoW'cd  loss  of 
coniidence  in  flying  and  exhibited  any  of  the  signs 
or  symptoms  of  Aero-Neuroses,  he  must  be  dis- 
charged from  the  air  station  as  unfit  for  further 
flying,  and  the  sooner  this  was  done  the  better  for 
all  concerned.  This  is  a  drastic  statement  to  make 
and  treatment  to  carry  out,  but  experience  has  eon- 


vinced  the  author  that  not  one  single  pupil  who  loses 
confidence  in  flying  and  develops  an  Aero-Neurosis 
ever  regains  that  confidence  or  goes  on  to  become 
a  qualified  aviator.     By  this  method  of  eliminating 
such  cases  at  once,  the  service  loses  a  certain  number 
of  pupils  (10  per  cent,  the  author  has  found,  some 
of    whom    might    have    succeeded    after    prolonging 
instruction) ;    but  to  counterbalance  that  and  more 
than  counterbalance  it,  this  rapid  elimination  method 
saves  instructors'  time  and  patience  (the  latter  being 
very  important),  saves  machines,  material  and  money, 
prevents   a   wave   of   Aero-Neuroses   spreading,    and 
saves   the   pupil   himself   from   perhaps   serious   dis- 
turbance  to   his   after-health.     Some    flying   officers 
break  down  even  after  they  liave  qualified  and  are 
ready  for  overseas.     Some   of  these  have   probably 
had  a  mental  struggle  during  their  pupil  days  which 
has  remained  undetected  or  unconfessed.     Perhaps 
some  of  these  with  appropriate  treatment  could  be 
reheved,    but    even    tliis    is    doubtful.     Throughout 
all  his  experience  the  author  has  always  found  that 
the  earlier  the  stage  of  onset  of  the  Neurosis  in  a 
flying  man's  career  the  more  hopeless  is  it  to  deal 
with  or  cure.     \Mien  a  flying  officer  has  done  fifty 
to    one    hundred   hours'    flying   it   is   always   worth 
while  making  an  effort  to  save  him  should  a  Neurosis 
set    in.     Before    deciding   finally    on   the   nature    of 
the  case  it  is  well  to  remember  that  there  arc  a  few 
malingerers  who  try  to  get  out  on  medical  grounds 
as   soon   as   they   have   qualified  ;     they   have   their 
*'  wings  "  and  like  to  retire,  retaining  these  without 
doing  any  more  seriovis  flying. 

To  summarise,  an  aerodrome  medical  officer  should 
treat  all  cases  on  their  merits,  consult  as  much  as 
possible  with  the  instructor,  classify  the  chnical 
type  of  Aero-Neurosis,  carry  out  investigation  with 
regard  to  further  tests  that  might  detect  such  cases 


earlier  and  incidentally  prove  or  disprove  the  tests 
for  admittance  to  the  Air  Force.  He  should  re- 
member tliat  the  earlier  the  onset  of  the  Aero-Xeurosis 
the  worse  the  prognosis.  Perhaps  some  medical 
officers  may  find  the  treatment  proposed  of  rapid 
elimination  of  such  cases  too  severe.  Any  method 
of  treatment  even  to  save  for  the  Service  the  ten 
per  cent,  wlio  are  rejected  would  be  welcome.  Some 
time  ago  a  suggestion  was  made  to  one  medical 
officer  to  carry  out  hypnotism  in  some  of  these 
eases,  but  so  far  nothing  has  been  heard  of  the 

The  "  Aero-Neurosis  "  of  War  Flying 

By    0.   H.    Gotch,   M.B.,    Ch.B.  {Oxon.),  M.R.C.P, 

{London).  Temporary  Surgeon,  R.N. 

The  following  remarks  and  suggestions  are  based 
on  the  notes  of  200  selected  cases  of  flying  officers 
who  have  broken  down  with  respect  to  flying  whilst 
on  war  service,  and  is  a  summary  of  the  year's  work 
wliilst  at  the  Central  Royal  Air  Force  Hospital, 

The  main  purpose  of  this  article  is  to  give  an 
aecoimt  of  the  "  Neuroses  "  of  war  flying  from  a 
purely  practical  standpoint,  and  to  describe  the 
examination  and  treatment  and  prognosis  of  the 
patient  in  a  way  that  might  serve  as  a  guide  to  an 
Air  Force  Medical  Officer  wlio  has  had  no  previous 

In  the  first  place,  the  most  essential  point  to 
realise  in  any  single  case  is  the  paramoimt  import- 
ance of  taking  a  very  detailed  and  full  history  of 
the  patients.  Quite  often,  after  a  laborious  question- 
ing of  the  patient  with  respect  to  his  history  and 
symptoms,    one    fails    to    elicit    anything    of    value 


which  can  explain  his  breakdown  until  some  point 
reveals  itself, — maybe  quite  a  trivial  one — which 
throws  a  most  unexpected  light  on  his  case.  Natu- 
rally such  a  procedure  is  often  exceedingly  tedious, 
and  in  any  case  is  laborious,  and  will  mean  that  it 
will  be  only  possible  to  examine  a  few  cases  in  one 
day.  Apart  from  the  time  spent,  the  question  of 
fatigue  on  the  part  of  the  medical  officer  is  obviously 
an  important  one.  Repeated  personal  experience 
has  shown  that  a  sketchy,  hm-riedly-taken  history 
is  generally  useless. 


Firstly,  there  is  (1)  Family  history.  The  number 
of  persons  in  any  community  who  have  a  completely 
negative  family  history  seems  to  be,  generally  speaking, 
small.  How  great  a  part  heredity  plays  in  our  lives 
may  be  indeterminable,  but  certainly  a  large  pro- 
portion of  the  patients  studied  at  the  Royal  Air 
Force  Hospital,  Hampstcad,  gave  evidence  of  some 
hereditary  "  nervous  instability "  either  on  the 
paternal  or  maternal  side,  or  both.  The  worst 
cases  almost  invariably  showed  some.  (Out  of  200 
cases,  167  had  a  positive  history  in  this  respect.) 

The  patient  is  asked  to  give  as  complete  an  account 
as  he  is  able  of  his  family  : — ^their  ages,  nationalities 
(particularly  as  to  any  Celtic  or  Hebrew  blood), 
and  habits ;  whether  there  is  any  alcoholism  or 
evidence  of  definite  mental  instability  or  eccen- 
tricity in  one  direction  or  another — their  attitude 
toward  worries  and  troubles  of  all  kind  :  whether 
or  no  they  have  ever  suffered  from  any  nervous 

Any  constitutional  disease  such  as  pulmonary  or 
other  forms  of  tuberculosis,  diabetes,  etc.,  are  of 
less  importance,  apart  from  epilepsy — but  the  exist- 
ence  of   "  rheumatism "   has,   in   a   few   cases,   been 


revealed  in  the  family  of  a  patient  (26  out  of  200)". 
A  family  history  of  epilepsy  or  of  asthma  should, 
of  course,  be  mentioned. 

A  thorough  investigation  of  the  family  history  in 
officers  who  have  failed  nearly  always  brings  out 
facts  which  fully  explain  his  failure  and  might,  if 
previously  known,  have  prevented  his  acceptance. 
On  the  other  hand,  those  cases  studied  of  "  Star 
Fliers  "  who  have  withstood  the  greatest  strain  in 
war  flying  without  any  symptoms  beyond  those  of 
physical  and  mental  fatigue,  have  nothing  in  their 
family  history  for  debate. 

In  ordinary  civil  practice  so  many  fine  points 
in  the  family  history  as  the  above  would  scarcely 
be  worth  mentioning,  but  in  the  case  of  the  flying 
officer  this  is  different.  The  experiences  he  daily 
imdergoes  whilst  on  war  flying  probably  involve 
the  greatest  strain  on  his  nervous  system  that  is 
possible  in  any  human  being,  and  it  is  reasonable  to 
suppose  that  any  slight  "  kink  "  in  his  hereditary 
nervous  disposition  might  give  way. 

During  his  civil  life  this  "  kink  "  would  never 
perhaps  show  itself.  Again,  the  average  age  of  war 
pilots  is  that  during  which  hereditary  influences 
become  most  obvious.  In  some  cases  it  will  be  found 
necessary  to  interview  the  parents  themselves  on 
points  which  the  patient  has  no  exact  knowledge 
or  which,  perhaps,  he  is  holding  back  from  the 
medical  officer  (such  as  alcoholism,  delirium  tremens, 
insanity,    etc.). 

Secondly,  there  is  the  history  of  the  patient  before 
he  joined  the  army.  To  find  out  as  much  as  possible 
of  his  infancy  and  childhood  is  important.  In  the 
first  place  there  is  his  np-bringing,  his  behaviour  pt 
home  and  at  school,  the  nature  and  extent  of  his 
work  and  play,  the  age  he  left  school.  His  health 
as  a  cliild  sliould  be  made  the  object  of  a  very  careful 


inquiry ;  whether  he  suffered  from  any  of  the 
so-called  "  fvuictional  nervous  disorders,"  such  as 
pavor  nocturnus,  somnambulism,  habit  spasms,  lien- 
teric  diarrhoea  and  nocturnal  eneuresis,  etc.,  or 
from  any  of  the  two  diseases  which  stand  in  common- 
est relationship  to  them — rickets  and  rheumatism. 
A  history  of  chorea  as  a  child  should,  of  course, 
receive  special  attention.  In  such  a  case  it  will  be 
necessary  to  write  to   or  to  interview  the  parents. 

Most  flying  officers  seem  to  be  derived  from  that 
class  engaged  in  some  industrial  business.  If  the 
patient  was  in  business  before  he  joined  the  army, 
a  brief  history  should  note  the  time  spent  in  it, 
whether  he  was  easily  or  difficultly  placed,  his 
interest,  opportunities  for  exercise,  sport,  and  other 
recreations,  etc.  An  account  of  the  general  health 
of  the  patient  should  include  any  nose  or  throat 
trouble,  chronic  coughs,  colds,  asthmatic  attacks, 
etc.  (any  operations  performed),  etc.  Of  the  specific 
infections,  "  rheumatism "  should  hold  the  first 
place  in  the  medical  officer's  mind.  Thus,  a  previous 
complaint  of  chronic  lieadache,  growing  pains,  tran- 
sient sore  throats  with  pain  in  the  sides  and  epi- 
gastrium, etc.,  etc.,  are  of  an  equal  degree  of  import- 
ance as  a  history  of  frank  rheumatic  arthritis. 

(A  history  of  "  rlieumatism,"  either  in  the  patient 
or  his  family,  was  noted  in  fifty-one  out  of  200  cases.) 

Then  there  is  the  question  as  to  whether  or  no 
the  patient  ever  suffered  with  the  same  symptoms 
as  the  present,  or  whether  he  ever,  in  any  way, 
broke  down  under  strain  before. 

Sometimes  at  first  a  negative  reply  is  given  when 
really  there  has  been  an  instance,  many  years  back, 
now  forgotten.  This  is  overlooked  until  a  leading 
question  happens  to  recall  it.  The  following  is  an 
example  : — 

Lieut.  R.,  aet.  21,  sent  back  after  three  and  a  half 


months'  duty  as  a  balloon  officer  observer.  Total 
hours  Avar  observing — ^twenty-one.  He  had  been 
forced  to  take  to  his  parachute  at  800  feet,  owing 
to  a  threat  of  fire  (the  balloon  had  escaped  damage) ; 
landed  quite  safely ;  no  injury ;  no  shock  and 
thought  nothing  of  it.  The  descent  in  a  parachute 
amused  him,  he  said.  Up  again  the  next  day. 
Two  nights  later  he  began  to  dream  of  the  experience, 
but  also  that  he  was  severely  burned  and  landed 
in  a  trench  in  a  dying  condition.  For  several  nights 
in  succession  this  same  type  of  dream  occurred,  but 
gradually  the  dream  took  on  a  different  character, 
and  the  flying  portion  of  it  disappeared  and  was 
replaced  by  unpleasant  dreams  connected  with  his 
life  at  home — that  he  had  burned  his  home  to  the 
ground  through  having  dropped  a  lighted  cigarette. 
Finally  he  became  exceedingly  "  nervy,"  continually 
apprehensive,  worried,  and  ill  at  ease.  He  was  sent 
home  as  a  case  of  "  debility,"  following  an  acute 
influenza  attack.  On  enquiring  into  his  pre-war 
history,  nothing  could  be  elicited  of  importance 
until,  after  much  hesitation,  he  remembered  that, 
when  a  boy,  aged  nine,  he  had  had  a  great  dread  of 
fireworks,  since  the  time  he  had  set  his  sister's  hair 
on  fire  with  a  Roman  candle  and  burnt  his  hand  as 
well.  He  remembered  being  extremely  upset  at 
the  time  and  of  dreaming  bad  nightmares.  Later, 
as  he  got  older,  and  after  joining  the  army,  he  had 
entirely  forgotten  all  about  the  incident,  until  a  few 
leading  questions  were  put  to  him,  when  he  recalled 
it.  Another  exactly  similar  type  of  case  has  been 

A  recent  history  of  a  nervous  breakdown  of  any 
kind  is  obviously  of  great  moment. 

If  the  patient  joined  some  infantry  regiment,  or 
other  branch  of  the  Service,  before  joining  the 
R.A.F.,  a  brief  account  of  his  military  history  should 


be  given.  Often,  in  fact  in  the  majority  of  cases, 
Avhatever  the  previovis  history  in  civil  Hfe,  good  or 
bad,  the  patients  generally  admit  that  they  never 
felt  so  well  as  during  the  first  few  months  of  their 
service  training.  Enquiry  should  be  made  about 
habits,  food,  drill,  discipline,  etc.  ;  how  much 
active  service  they  underwent,  and  finally  their 
reasons  for  joining  the  R.A.F.  Naturally,  most  of 
them  say  that  they  have  been  attracted  to  flying  for 
its  own  sake.  Some  may  have  had  a  previous 
interest  in  it,  practically  or  theoretically ;  others 
frankly  admit  that  their  original  motive  was  to 
escape  the  routine  military  life,  either  at  home  or 
abroad,  and  that  they  had  no  real  genuine  interest 
in  flying  apart  from  the  novelty  and  change.  (Num- 
ber of  cases  with  previous  military  or  other  Service 
experience — 106.) 

The  health  of  the  patient  during  this  time  should 
include  accurate  dates  as  to  any  sickness,  the  names 
of  any  hospitals  to  which  he  was  sent,  and  the  time 
he  was  officially  on  the  sick-list.  A  history  of  any 
*'  fever,"  whether  termed  "  trench  fever "  or 
*'  pyrexia  of  uncertain  origin,"  or  any  specific  fever, 
an  acute,  sub-acute,  or  chronic  diarrhoea  or  gastric 
complaint  should  be  noted  and  taken  into  account 
during  the  physical  examination.  A  history  of 
bleeding  gums  at  any  time,  however  trivial,  should 
never  escape  attention.  The  next  part  of  the 
history  should  contain  an  accurate  account  of  his 
flying  experience. 

In  the  case  of  a  pilot  under  instruction  : — 

(1)  Number  of  hours  dual  control. 

(2)  AMiat  machine  he  first  flew  solo. 

(3)  His  sensations  whilst  performing  aerobatics. 

(4)  Any    doubts    or    apprehension    about    any 



(5)  His  landings. 

(6)  His  relations  with  his  instructor. 

(7)  Any  crashes  or  accidents  of  any  kind. 

(8)  His  confidence  when  graduated,  etc. 

In  the  case  of  a  qualified  pilot  on  active  service  : 

(1)  Types  of  machine  flown. 

(2)  Total  hours  flown  over  the  lines  (and  the 

number  of  hours  flown  apart  from  war 

(3)  Average  height. 

(4)  Greatest  height. 

(5)  Work  done  whilst  flying. 

(6)  Experience  with  enemy  aircraft. 

(7)  Whether  forced  down,  shot  down,  or  crashed 

(and  a  detailed  description  of  same  if 

(8)  Any  "  high  altitude  "  sensations  before  or 

after  landing,  etc. 

(9)  "Wliether  he  saw  any  machines  crash  (espe- 

cially machines  from  his  own  squadron), 
catch  fire,  etc.,  and  his  impressions  at 
the  time. 

(10)  His    confidence    over    the    lines,     and    in 

handling  emergencies,  etc. 

(11)  His  landings. 

(12)  His  present  flying  confidence. 

These  and  other  minor  points  connected  with  his 
flying  experiences  deserve  a  detailed  description. 

Or,  in  the  case  of  an  observer,  in  addition  to  most 
of  the  points  mentioned  above,  it  will  be  necessary 
to  knt)w  : — 

(1)  His   confidence   in,    and   relations   with,   his 


(2)  Whether  lie  liad  the  same  pilot  during  the 

whole  of  his  service  in  France. 

(3)  Whether  he  flew  with  different  pilots. 


It  is  generally  admitted  that  an  observer  has  a 
far  greater  strain  imposed  upon  him  than  a  pilot, 
for  the  following  reasons  : — 

(a)  An}^  loss  of  confidence  in  his  pilot  will  mean 
a  correspondingly  greater  degree  of  anxiety  in  that 

(b)  A  crash  (especially  if  the  machine  is  falling 
from  some  height)  will  give  him  sufficient  time  to 
anticipate  the  fall  in  his  imagination  (whilst  the 
pilot  has  his  attention  occupied  in  handling  his 

(c)  An  observer  has  to  keep  a  constant  look-out 
for  enemy  aircraft,  etc.,  during  the  time  he  is  taking 
photographs,  or  making  other  observations  (not  to 
speak  of  handling  his  gun  at  a  moment's  notice). 

The  above  points  explain  why  it  is  that  observers 
generally  break  down  sooner  and  to  a  much  greater 
degree  than  pilots.  In  the  case  of  a  balloon  observer 
it  is  important  to  know  whether  (and  how  many 
times)  he  had  to  take  to  his  parachute  or  whether 
the  balloon  was  attacked  or  set  on  fire — and  of  any 
psychical  sequelae  that  may  have  followed  from 
such  experiences. 

The  patient's  habits  and  general  health  whilst 
on  active  service  should  next  be  studied,  viz.  : — 

(1)  How  much  alcoholic  drink  he  took,  and  when 

he  took  it  :  whether  he  took  stimulants 
before  going  up  "  to  nerve  himself  for  a 
fight,"  etc. 

(2)  The  amount  of  tobacco  smoked  {i.e.  number  of 

cigarettes  and  pipes  smoked  in  a  day). 

(3)  Exercise  taken  whilst  off  duty. 

(4)  \Mi ether  he  ever  suffered  from  any  venereal 

disease  and  if  so  the  treatment  he  under- 


(5)  Whether  he  was  ever  ill  with  fever,  etc. 

{6)  Whether  he   suffered   from   bleeding  gums   or 

dry  mouth  whilst  flying. 
{7)  Any    temporary    ailment,     however     trifling, 

which  may  have  thrown  him  off  his  balance 

for  a  day  or  two. 
(8)  His  present  symptoms. 

With  such  facts  as  these  one  will  be,  in  some 
measure,  capable  of  forming  a  decision  on  the  history 
of  his  breakdown,  its  bearing  on  his  present  condition 
and  on  his  future  prospects. 

If  the  breakdown  followed  a  crash,  it  will  be 
necessary  to  know  the  exact  circumstances  in  which 
the  crash  occurred,  as  far  as  he  can  remember  them, 
whether  he  felt  quite  well  or  '*  off  colour  "  on  the 
day  he  crashed,  whether  he  had  taken  sufficient 
food,  etc. 

There  is  no  need  to  describe  the  method  of  clinical 
examination,  but  it  may  be  permissible  to  emphasise 
one  or  two  points. 

(1)  It  is  advisable  to  make  a  routine  clinical 
examination  prior  to  employing  any  of  the  valuable 
physiological  tests  in  use  at  present,  since  several 
cases  have  come  to  my  notice  in  which  patients 
with  florid  secondary  syphilis  and  active  pulmonary 
tuberculosis  have  been  tested  with  physiologi- 
cal apparatus  before  a  clinical  examination  has 
been  made,  with  a  possible  risk  of  infection  to 

(2)  The  teeth  and  gums  and  naso-pharynx  and 
auditory  apparatus  should  be  most  carefully  in- 
spected, especially  noting  the  presence  or  absence 
of  any  oral  sepsis,  however  slight.  It  is  obviously 
important  to  eliminate  any  possible  toxic  element  in  a 
case  which  might  be  aggravating  the  condition  of 
^'  breakdown." 


Types  of  Cases 

The  cases,  judging  from  personal  experience,  seem 
to  fall  into  six  main  groups. 

(1)  Those  who  are  merely  physically  or  mentally 
tired — "  stale  "—with  nothing  to  complicate  the 

(2)  Those  in  whom  the  breakdown  as  regards 
flying  has  a  purely  mental  origin,  i.e.  something 
unpleasant,  some  experience  has  impressed  itself 
on  them  giving  rise  to  a  persistently  disagreeable 
memory.  In  time  the  impression  may  act  sub- 
consciously and  gradually  give  rise  to  symptoms  or 
signs  referable  to  the  cardio- vascular,  central 
nervous,  respiratory,  or  abdominal  systems  (to  be 
discussed  later).  The  writer  is  convinced  that  the 
vast  majority  of  all  the  cases  of  "  breakdown  "  with 
respect  to  flying  (in  which  the  toxic  element  can  be 
excluded)  start  purely  mentally,  from  an  impression, 
an  experience,  or  an  act,  etc.,  and  that  the  symptoms 
and  signs  found  later  are  secondary  to  the  primary 
mental  cause. 

(3)  Those  cases  in  which  the  toxic  element  has 
been  the  deciding  factor  in  the  "  breakdown."  Of 
these,  the  commonest  seen  at  this  hospital  have  been 
(in  order  of  frequency) — [a)  oral  sepsis ;  (h)  in- 
fluenza ;  (c)  malaria ;  {d)  dysentery ;  {e)  syphilis ; 
(/)  obscure  rheumatic-like  infections,  termed  col- 
lectively as  "  trench  fever  "  ;  (g)  tuberculosis  ;  (h) 
chronic  nephritis.  The  purely  toxic  patient,  when 
the  toxic  factor  has  been  removed,  has  made  an 
apparently  complete  recovery,  with  resumption  of 
full  flying  duties  under  war  conditions. 

(4)  Those  who  suffer  from  a  psychopathy,  i.e. 
from  a  disorder  of  conduct.  Such  a  flying  officer  is 
generally  sent  home  with  a  history  stating  that  he 
is    quite    untrustworthy,    though    brave    and    some- 


times  capable,  and  that  under  certain  conditions  of 
service  he  is  entirely  inefficient.  For  example,  such 
a  patient  may  be  found  to  do  good  work  at  one 
squadron,  but  if  transferred  to  another  may  be 
found  unsatisfactory.  He  "will  take  a  dislike  to  his 
commanding  officer,  or  to  members  of  his  mess  :  he 
will  refuse  to  carry  out  his  work  unless  allowed  to 
do  as  he  pleases.  When  examined  at  this  hospital 
such  a  patient  may  be  found  to  be  abnormal  in  many 
Avays.  He  has  little  regard  for  truth  ;  will  state 
that  he  has  done  500  hours'  flying  when  in  reality 
he  has  only  done  50,  or  record  incredible  adventures 
in  the  air.  His  private  life  may  be  also  found  to 
run  on  similar  lines  {e.g.  one  patient  told  the  writer 
tliat  he  was  twenty-one  and  unmarried,  when  in 
reality  he  was  a  married  man  of  twenty-nine  with 
a  child  and  had  recently  been  charged  with  bigamy). 
To  say  that  such  cases  belong  to  the  criminal  type  is, 
perhaps,  too  strong,  but  from  the  flying  point  of 
view  at  any  rate  they  can  hardly  be  counted  as 
satisfactory  flying  officers  except  when  placed  under 
very  special  conditions  of  service  which  happen  to 
suit  their  temperament.  That  they  are  occasionally 
supernaturally  brave  and  daring  (and  hence,  often 
invaluable  as  "  roving  pilots  ")  is  undeniable,  but 
otherwise  they  appear  to  be  quite  unsuited  to  lead 
a  formation  or  to  be  entrusted  with  any  responsible 
command.  They  should,  of  course,  only  be  allowed 
to  fly  single-seaters,  out  of  consideration  for  the 
observer  or  passenger  they  carry. 

(5)  Those  cases  whose  flying  disability  has  been 
ultimately  traced  to  a  purely  "  physical  "  cause  (as 
opposed  to  a  psychical  origin)  the  result  of  (a)  true 
oxygen  want  at  high  altitudes  ;  (b)  air  sickness ; 
(c)  giddiness  in  the  air ;  (d)  "  concealed  squint," 
etc.  A  good  many  cases  of  true  oxygen  want  have 
been  described  ;    personally  the  writer  has  only  seen 


one  genuinely  proved  case.  All  the  other  cases  of 
supposed  oxygen  want  have  been  ultimately  traced 
to  a  psychical  foundation  and  proved  by  actual 

(6)  Malingerers.  This  class  may  be  more  numerous 
than  is  supposed,  but  it  is  exceedingly  diflficult  to 
prove  that  any  patient  is  definitely  malingering. 
Nevertheless,  one  must  always  be  on  one's  guard 
against  the  type  of  flying  officer  who  really  does  not 
want  to  fly  and  who  knows  that  the  medical  officer 
thinks  him  unfit  for  flying.  Such  an  officer  will 
stoutly  maintain  his  keenness  to  continue  flying, 
hoping  thereby  that  he  may  retain  his  flying  pay, 
should  he  be  able  to  persuade  the  medical  officer  to 
prescribe  "  limited  flying." 

At  this  point  it  is  necessary  to  add  that  "  mixed  " 
classes  of  the  types  2  and  3  are  extremely  common, 
i.e.  in  which  an  aviator  has  mentally  broken  down 
and  whose  condition  is  complicated  by  some  toxic 
factor  such  as  influenza,  oral  sepsis,  etc.  In  such 
cases  a  cure  of  the  toxic  element,  though  improving 
the  general  condition  and  particularly  the  symptoms 
of  exhaustion,  fatigue,  loss  of  power,  of  mental  con- 
centration, etc.,  will  not  restore  confidence  in  flying. 

The  above  classification  is  only  intended  to  be  a 
preliminary  attempt  as  a  practical  guide  to  the 
medical  officer  who  examines  a  number  of  patients 
for  the  first  time.  Further  experience  will  no  doubt 
improve  this  classification. 

Clinical  Signs 

(1)  In  the  first  type  of  case  there  are  no  physical 
signs  of  any  objective  importance.  The  patient  will 
merely  state  that  he  is  tired  and  "  stale,"  and  would 
appreciate  a  rest  from  flying.  On  questioning  a 
patient  as  to  his  symptoms,  he  will  often  admit 
that  the  first  intimation  he  had  of  his  staleness  was 


a  failure  to  make  his  usual  good  landings.  He 
accuses  himself  of  carelessness,  and  will  often  get 
depressed  about  his  loss  of  skill  in  this  respect. 
*'  I  do  everything  as  usual,"  he  says,  "  but  for  some 
reason  or  other  I  can't  help  making  '  dud  '  landings, 
or  "  I  might  be  only  just  beginning  to  learn  flying, 
judging  by  my  performances  lately,"  and  so  on. 

There  is  no  "  apprehension  "  factor  in  this  type 
of  case,  no  real  loss  of  confidence  The  patient  is 
merely  physically  and  mentally  tired,  and  is  mani- 
festing his  condition  in  a  perfectly  normal  fashion. 

His  depression  is  natural,  but  it  may,  of  course, 
bring  "vvith  it  a  more  serious  condition  of  things, 
viz.  : — broken  sleep,  loss  of  interest,  and  ultimately 
of  confidence  in  flying. 

(2)  In  the  second  type  of  case  the  clinical  symp- 
toms and  signs  are  exceedingly  complex  and  difficult 
to  unravel  and  explain.  In  such  cases  a  complete 
history  is  essential  to  discover  the  starting  point 
in  the  breakdown. 

With  his  present  experience  the  writer  is  forced  to 
admit  that  the  starting  point  is  practically  always  a 
mental  one.  The  clinical  signs  in  these  cases  seem  to 
be  the  expression  of  some  disturbance  of  the  central 
nervous  system  as  a  whole,  which,  in  their  turn,  are 
secondary  to  a  mental  disturbance.  In  what  way 
and  by  what  steps  this  secondary  disturbance  of 
the  central  nervous  system  arises  it  is  impossible 
to  say,  but  the  clinical  signs  in  a  typical  case  are 
very  interesting,  and  appear  to  point  to  a  hyper- 
irritability  and  instability  of  the  central  nervous 
system,  and  in  particular  of  the  medullary  centres 
governing  the  action  of  respiration,  the  vaso-motor 
system,  the  vagal  system,  and  even  other  cranial 

It  is  not  within  the  scope  of  this  article  to  offer 
any  explanation  of  this  type  of  case  and  the  physical 


signs  connected  with  it.  One  would  only  be  led 
into  an  attempt  to  explain  the  cause  of  the  ailments 
from  which  the  majority  of  the  whole  human  race 

It  seems  extremely  unlikely  that  the  physical 
signs  as  found  in  this  type  of  case  are  confined  to 
flying  officers,  i.e.,  congestion  of  the  face  and  poor 
pulse  response  during  the  "  fatigue  test,"  failure 
to  hold  the  breath  beyond  a  certain  limit,  "  gastric 
splashing,"  rapid  pulse,  high  pulse  pressure,  head- 
aches, increased  tendon  reflexes,  digital  tremor, 
etc.,  etc.  We  should  expect  to  find  them  all  in  any 
individual  suffering  from  an  "  occupation  neurosis  " 
or  a  "  traumatic  neurasthenia,"  where  a  mental 
shock  or  strain  seems  to  have  set  in  motion  a  whole 
number  of  concrete  signs  and  symptoms  formerly 
described,  for  want  of  a  better  word,  as  "  functional." 

In  examining  this  type  of  fiying  officer  patient, 
one  need  not  go  far  afield  to  prove  that  his  central 
nervous  system  as  a  whole  is  in  a  state  of  disturbance. 

He  complains  of  a  great  depression,  apprehension, 
extreme  irritability,  change  of  character,  a  morbid 
desire  to  be  alone,  a  lack  of  power  to  concentrate  on 
any  subject  at  any  given  time,  a  failure  of  memory, 
lack  of  energy,  lack  of  interest,  loss  of  the  natural 
pleasure  of  being  alive,  sleeplessness,  dreams  and 
nightmares,  all  pointing  to  a  morbid  condition 
of  his  higher  centres.  There  is  also  a  complaint  of 
breathlessness  and  an  undue  sense  of  fatigue  on 
exertion,  of  an  unpleasant  consciousness  of  the 
heart's  action,  perhaps  palpitation  and  intermit- 
tency  ;  of  headache  (particularly  of  a  paroxysmal 
nature — probably  vaso-motor  in  origin),  etc.  We 
find  a  flushing  of  the  face  (sometimes  unilateral — 
four  cases)  to  a  very  slight  stimulus,  of  excessive 
perspiration,  digital  tremor  and  marked  increase 
of  the  tendon  reflexes  (in  others,  an  extremely  sluggish 


condition  of  the  tendon  reflexes — eighteen  cases). 
Nine  cases  have  shown  curions  pupil  abnormaUties, 
presumably  of  central  origin.  The  pupils  were 
unequal,  and  one  or  both  reacted  sluggishly  to  light 
and  accommodation  (four  cases  only  showed  these 
signs  when  the  eye  had  become  dark-adapted). 
Seven  of  the  above  cases  were  seen  again  five  months 
later,  and  the  pupils  reacted  perfectly  normally. 
Incidentally,  the  general  condition  of  these  patients 
had  returned  to  normal.  Stammering  has  been 
noted  in  twenty-eight  cases  ;  two  cases  were  appar- 
ently totalh^  amnesic  on  admission ;  twelve  cases 
showed  general  tic-like  movements  of  head  and  limbs. 
It  would,  perhaps,  not  be  out  of  place  to  quote  a 
few  of  the  cases  under  discussion,  thereby  demon- 
strating their  complexity. 

(1)  Lieut.  Pilot,  aet.  twenty-one,  complained  of 
a  tight  feeling  in  both  nostrils  of  a  month's  duration  ; 
he  said  that  he  could  not  breathe  through  them 
properly.  He  was  anxious  for  an  operation  to  cure 
the  condition.  Flying  history  : — 260  hours'  war 
flying.  Two  recent  crashes,  no  injury  but  slight 
shock.  Flew  twenty-six  hours  after  the  last  crash. 
No  loss  of  confidence  in  flying,  but  admits  to  having 
dreamed  of  the  crashes  ever  since  they  had  occurred 
(last  crash — six  weeks  ago).  On  examination  : — 
no  abnormality  could  be  discovered  in  the  naso- 
pharynx, and  he  was  assured  that  there  was  nothing 
the  matter  ;  but  his  reflexes,  however,  were  increased, 
and  there  was  some  slight  digital  tremor.  His 
previous  history  was  unimportant,  save  that  ten 
years  previously  a  nasal  polypus  had  been  removed 
from  the  right  nostril,  and  his  health  at  that  time 
was  poor.  Previous  to  the  operation  he  had  had 
a  nasal  discharge  and  difficulty  with  nasal  breathing. 

He  failed  in  the  physiological  tests  instituted  by 
Lieut. -Colonel     Flack,     and    his    general    condition 


seemed  to  point  to  an  early  fatigue  of  the  central 
nervous  system.  His  complaint  about  his  nose 
might  be  put  down  to  a  re-awakening  of  the  by-golie 
memory  of  his  former  nasal  trouble,  and  was  an 
expression  of  his  "  central  fatigue."  In  three  months 
he  was  perfectly  well  and  declared  that  his  nose 
complaint  must  have  been  pure  imagination. 

Captain   Y.,    aet.   27,   pilot. 

Sent  home  as  a  case  of  oxygen  want,  with  a  recom- 
mendation to  fly  at  low  altitudes  only.  Complained 
of  feeling  exceedingly  faint  when  flying  at  12,000 
feet,  but  not  at  lower  altitudes.  First  noticed  symp- 
toms six  weeks  ago.  Previously  had  had  no  symp- 
toms. Total  hours,  250.  Excellent  flying  record. 
At  the  time  of  examination  complained  of  no  symp- 
toms, except  those  of  faintness,  breathlessness  and 
giddiness,  and  loss  of  power  to  control  the  machine 
at  high  altitudes.  Otherwise  was  feeling  quite  well, 
but  admitted  sleeping  badly  since  the  symptoms 
started.  Dreamed  a  good  deal  of  flying,  but  not 
unpleasantly.  Had  also  noticed  himself  sometimes 
utterly  unable  to  find  his  word  when  addressing 
a  fellow  officer  or  his  CO.,  and  that  his  hands 
shook  when  holding  a  knife  and  fork.  Previous 
history  negative,  but  his  flying  history  had  been 
full.  Has  had  several  forced  landings  and  twice 
sustained  very  slight  flesh  wounds  from  shrapnel, 
but  not  bad  enough  to  send  him  to  hospital.  Three 
months  ago  his  engine  failed  at  12,000  feet  when  he 
was  six  miles  over  the  lines,  and  he  admitted  being 
nervous  after  the  incident.  On  examination,  there 
was  some  digital  tremor,  and  tendon  hyper-re  flexia. 
His  general  appearance  was  that  of  a  somewhat 
highly-strung  individual.  Talked  rather  aimlessly 
about  his  condition  and  had  a  slight  stammer.  On 
testing  his  condition  at  high  altitudes  by  means  of 
physiological    apparatus,    it    was    found    that    his 


oxygen  want  must  have  been  entirely  the  result  of 
auto-suggestion,  since  lie  was  made  to  breathe  in  an 
atmosphere  of  18,000  feet  without,  any  symptoms 
whatever.  The  neurosis  from  which  he  was  suffering 
seemed  to  have  arisen  from  the  day  his  engine  failed 
at  12,000  feet.  A  great  many  similar  cases  have 
been  seen  at  the  hospital.  In  the  case  of  the  above 
l)atient  an  ulcer  was  present  on  the  right  tonsil 
resembling  a  Vincent's  Angina,  which  eventually 
healed  imder  treatment.  There  was  a  great  deal 
of  chronic  oral  sepsis  which  was  also  treated  very 
thoroughly  and  a  relapse  prevented.  When  seen 
three  months  later  at  an  Appeal  Board,  he  wished 
to  start  flying  "  scouts  "  again,  and  did  not  com- 
plain of  any  symptoms,  and  had  done  some  high 
flying  as  a  passenger. 

(2)  Lieut.  Z.,  aet.  28,  pilot. 

Canadian  by  birth  ;  complained  of  a  feeling  of 
great  exhaustion,  sleeplessness,  and  apprehension 
as  regards  flying  over  the  lines,  though  denying  any 
loss  of  confidence  in  flying  apart  from  this.  His 
machine  had  been  hit  by  anti-aircraft  fire  at  19,000 
feet  whilst  on  patrol  with  other  machines  a  fortnight 
before  the  onset  of  symptoms.  There  had  been  no 
previous  warning  of  any  anti-aircraft  barrage,  and 
the  "  hit  "  in  his  case  must  have  been  a  chance  shot. 
His  machine  fell  to  5,000  feet,  but  he  managed  to 
regain  partial  control,  and  eventually  landed  before 
the  machine  caught  fire.  He  was  throAvn  out,  but 
did  not  hurt  himself,  and  walking  to  a  hut  a  few 
yards  away  found  it  belonged  to  a  regimental  mess. 
He  received  immediate  attention,  and  offered  to 
fly  back  to  his  squadron,  but  was  taken  back  in  a 
lorry.  Felt  quite  well  the  next  day,  but  was  pro- 
hibited flying  by  his  CO.,  who  said  that  he  looked 
very  unfit.  Three  days  later  he  complained  of  sleep- 
lessness and  nightmares  of  an  extremely  vivid  char- 


acter.  He  kept  thinking  about  his  extraordinary 
ill-hick  at  being  hit  at  19,000  feet,  above  the  clouds. 
Was  finally  sent  home  as  unfit,  though  he  himself 
wished  to  fly  and  get  his  nerve  back  again.  Total 
hours — 100  (in  France).  His  previous  and  family 
history  were  not  altogether  satisfactory.  His  father 
had  had  several  attacks  of  delirium  tremens, 
eventually  left  home  and  had  never  since  been 
traced.  The  patient  admitted  that  whilst  in  France 
he  had  taken  drink  to  excess,  "  to  keep  his  end  up," 
so  he  said,  and  had  latterly  taken  "  several  whiskeys  " 
during  the  night  to  make  him  sleep.  He  had  been 
in  the  cinematogi'aph  business  before  joining  the 
army.  On  examination,  his  general  physique  appeared 
very  good  but  he  appeared  restless,  ill  at  ease,  and 
constantly  walked  about  whilst  he  talked.  There 
was  a  distinct  antero-posterior  tremor  of  the  tongue, 
and  a  fine  tremor  of  the  lips  and  fingers  ;  the  tendon 
reflexes  were  not  exaggerated.  He  was  kept  in 
bed  for  a  week  and  given  ammonium  bromide  mix- 
ture 20  gr.  t.d.s.,  and  his  general  behaviour  and 
condition  carefully  watched  from  day  to  day.  His 
mental  condition  became  very  much  better,  though 
the  tremors  increased  for  a  few  days  after  treatment 
had  been  instituted.  The  question  naturally  arose 
as  to  what  part  the  alcoholic  factor  played  in  his 
condition,  and  whether  he  would  have  broken  down 
through  that  alone,  supposing  he  had  had  no  flying 
accident.  He  seemed  a  stout-hearted  individual, 
and  could  not  properly  be  called  a  neurasthenic. 
His  work  in  France  had  apparently  been  very  satis- 
factory until  the  accident.  The  prognosis  in  such 
a  case  was  obviously  a  matter  of  some  difficulty. 
He  was  very  seriously  warned  about  the  dangers  of 
alcoholic  excess  and  finally  sent  on  leave,  and 
"  limited  flying  "  recommended. 

Many     more    examples    showing    the     individual 


character  of  the  cases  seen  might  be  given,  but 
without  quoting  any  further  cases  it  is  ob\ious  that 
each  patient  must  receive  a  very  individual  atten- 
tion and  a  painstaking  examination,  otherwise  the 
whole  origin  of  the  trouble  might  be  entirely  missed. 

(3)  In  the  third  type  of  case  the  outstanding  symp- 
toms are  a  continuous  feeling  of  fatigue,  weariness 
of  the  limbs  after  a  little  exertion,  a  feeling  of  general 
lassitude  and  exhaustion,  and  of  mental  dullness, 
particularly  towards  the  end  of  the  day.  A  patient 
with  a  preponderance  of  such  symptoms,  especially 
where  there  appears  to  be  no  direct  cause  for  the 
breakdown  with  respect  to  fl^^ing,  should  be  assumed 
to  be  suffering  from  some  toxic  factor  unless  this  is 
proved  to  be  otherwise.  Steps  must  be  taken  to 
discover  what  is  the  nature  of  the  toxicity.  The 
teeth  should  be  carefully  examined  ;  account  should 
be  taken  of  any  temporary  ailment,  etc.  ;  in  short, 
a  thorough  medical  examination  will  be  necessary. 

(4)  In  the  fourth  type  of  case  the  physical  signs 
are  rather  characteristic.  The  patient  appears 
objectively  normal.  He  does  well  in  all  the  physio- 
logical tests — perhaps  too  well.  There  are  no  demon- 
strable signs  of  any  moment ;  a  few  minutes'  con- 
versation, however,  with  such  a  patient  will  be 
enough  to  settle  any  doubts  as  regards  his  condition. 
The  writer  remembers  one  of  such  patients  who, 
seeing  him  for  the  first  time,  offered  a  cheque  for 
live  pounds  (which  he  had  already  made  out  in  his 
name)  if  he  could  get  him  a  special  job  in  France 
away  from  his  CO.,  whom  he  detested.  Another 
patient,  under  the  care  of  Surgeon  Anderson,  insisted 
on  his  false  teeth  being  sent  out  to  France,  as  he 
could  not  wait  for  them  to  be  fitted  in  hospital. 
He  declined  leave,  and  refused  to  do  any  other  form 
of  duty  except  flying  in  France.  Such  patients 
have   been  termed   "  Impulsifs  "   by  French   neuro- 


legists,  and  are  quite  incurable.  They  will  go 
through  life  in  this  fashion.  How  far,  and  to  what 
extent,  war  conditions  accentuate  their  abnormality 
it  is  hard  to  say.  Suffice  it  that  such  patients  are 
quite  recognisable  at  first  glance,  and  the  only 
difficulty  will  be  to  determine  whether  or  not  they 
should  continue  flying.  All  persuasion  and  influence 
or  any  sort  of  treatment  is  generally  quite  useless. 

(5)  The  fifth  type  of  case  is  recognised  by  demon- 
strating the  presence  of  oxygen-want,  "  concealed 
squint,"  etc.,  and  the  tests  carried  out  with  physio- 
logical apparatus.  This  is  not  the  place  to  describe 
such  cases,  since  they  do  not  belong  to  the  present 


The  ideal  aim  of  treatment  in  the  above  cases 
is  obviously  to  make  a  broken-down  flying  officer  fit 
again  for  war  service  with  the  same  confidence  as 
he  had  had  previously  (reference  to  the  classifica- 
tion of  cases  will  assist  discussion  on  this  point). 

In  the  case  of  type  (1) — Here  we  have  a  normal 
individual  who  is  temporarily  "  stale  "  and  requires 
rest — mental  and  physical.  Treatment  in  his  case 
is  a  comparatively  simple  matter.  After  a  thorough 
clinical  examination  whereby  all  complicating  factors 
should  be  excluded,  he  may  be  given  the  maximum 
amount  of  leave  permissible  under  R.A.F.  regula- 
tions, or  if  this  is  not  deemed  sufficient,  a  month's 
stay  at  a  suitable  convalescent  home  (of  which  those 
attached  to  the  Royal  Air  Force  hospital  are  ideal 
in  every  respect),  with  a  further  period  of  four  weeks^ 

In  the  case  of  veiy  special  "  long  service  colonial 
cases,"  three  months'  leave  to  Canada,  South  Africa, 
or  Australia,  may  be  advisable,  but  this  is  rarely 


In  our  experience,  it  is  a  distinct  mistake  to  extend 
the  leave  away  from  any  form  of  duty  connected 
with  flying  beyond  a  certain  limit,  as  several  patients 
who  have  reported  themselves  at  the  end  of  an 
extended  leave  for  a  INIedical  Board  have  shown  a 
total  loss  of  flying  confidence. 

This  can  only  mean  that  too  much  unemployed 
time  away  from  any  form  of  duty  connected  with 
flying  has  a  deleterious  effect  on  the  flying  confidence 
of  an  officer  who,  when  given  leave,  was  merely  tired, 
but  with  his  flying  confidence  unimpaired.  In  other 
words,  care  should  be  taken  not  to  convert  the 
tired  officer  into  a  chronic  convalescent. 

Just  sufficient  unemployed  time  should  be  given 
according  to  the  case  to  enable  a  satisfactory  bodily 
and  mental  rest  and  no  more.  The  minimum  is 
three  weeks,  and  the  maximum  is  ten  weeks  (except 
in  very  special  cases  of  officers  of  exceptional  ability 
who  have  seen  a  great  deal  of  flying  service). 

Too  much  time  off  duty  is  just  as  great  a  mistake 
as  too  little  rest  away  from  duty. 

At  the  end  of  the  leave  Home  Service  for  a  certain 
amount  of  time  is  advisable. 

It  is  not  possible  to  give  any  figures  of  very  much 
value,  smce  comparatively  few  merely  tired  flying 
officers  have  been  seen  as  in-patients.  Out  of 
twenty-eight  cases,  nineteen  have  reported  them- 
selves back  at  flying  duties  either  in  England  or  in 
France  apparently  well  and  with  full  flying  con- 
fidence. Of  the  remaining  nine  cases,  five  lost 
their  confidence  and  gave  up  flying  ;  the  remaining 
four  have  not  been  traced. 

(2)  In  the  case  of  the  flying  officer  who  has  broken 
down  in  the  manner  described  under  the  second 
type  of  case,  treatment  is  a  matter  of  considerable 
difficulty.  In  the  first  place,  any  officer  who  has 
been  rendered  unconscious  through  a  blow  or  injury 



to  his  head  following  an  accident,  should  be  strictly 
kept  in  bed  from  two  to  three  weeks  following  the 
accident,  no  matter  how  quickly  he  may  seem  to 
improve.  We  have  seen  a  great  many  cases  of 
officers  with  no  physical  signs  of  organic  injury 
complaining  of  headaches,  depression,  nervousness, 
and  loss  of  flying  confidence,  some,  indeed,  totally 
unfit  for  any  form  of  duty,  who  stated  that  they 
were  in  bed  only  two  or  three  days  following  a  serious 
crash  with  loss  of  consciousness.  They  had  been 
allowed  up  and  sent  on  leave,  and  the  symptoms 
had  developed  after  a  certain  variable  latent  period. 

Other  patients  whose  symptoms  have  not  been 
the  immediate  result  of  concussion  should  invariably 
receive  a  thorough  medical  examination  before 
sending  them  away  on  sick  leave.  The  process  of 
a  thorough  history  taking  and  examination  followed 
by  a  sympathetic  conversation  is  often  a  great 
relief  to  the  patient  who,  perhaps,  was  afraid  to 
open  his  mind  fully  before.  Incidentally,  a  complete 
sympathy  between  doctor  and  patient  is,  of  course, 
absolutely  necessaiy.  The  patient  should  feel  that 
he  is  receiving  the  most  individual  care  and  attention. 

Any  "  repression "  connected  with  the  mental 
condition  of  the  patient  should  receive  special  exam- 
ination, and  an  attempt  be  made  to  relieve  the 
mental  distress  and  worry. 

To  send  a  patient  away  on  sick  leave  who  com- 
plains of  sleeplessness,  headaches,  nightmares,  and 
shows  signs  of  general  nervous  instability  without 
any  further  word  or  examination,  is  to  condemn 
him  to  a  great  deal  of  mental  and  physical  suffering 
and  might  end  in  seriously  impeding  his  chances  of 
improvement  for  fitness  in  any  capacity  whether 
military  or  otherwise. 

Every  patient  sent  from  France  with  a  history  of 
*'  Flying   Neurasthenia "    should   be   under   medical 


supervision  until  the  medical  officer  is  satisfied  that 
he  will  improve  without  any  special  medical  attention. 
In  a  case  of  average  severity  with  broken  sleep, 
nightmares,  irritability,  apprehension,  depression,  and 
well-marked  signs  of  "  nervous  instability,"  such  as 
a  stammer,  increased  reflexes,  tremor,  and  inco- 
ordination, it  is  generally  wise  to  adopt  the  plan  of 
rest  in  bed  for  a  week  (according  to  the  symptoms 
and  signs)  and  to  prescribe  an  ammonium  bromide 
mixture  to  be  taken  t.d.s.  The  following  gives  the 
best  results  : — 

Ammon.  brom.  gr.  xx. 

Liq.  arsenicalis  m.  iii. 

Tinct.  ealumbae  m.  x. 

Ferri  et  ammon.  cit.  gr.  x. 
Aq.  chloroform  add   oz.  i. 

Small  doses  of  the  bromide  are  not  of  much  service. 
It  is  best  to  give  not  less  than  15,  or  more  than 
30  grs.  t.d.s. 

On  the  whole,  ammon.  bromide  is  the  best  bromide 
salt,  and  it  is  seldom  necessary  to  resort  to  any  other 
drug.  For  troublesome  insomnia,  trional  grs.  v.-  grs.  x. 
at  night  is  the  most  certain  remedy.  It  gives  the 
quickest  and  most  certain  results.  In  cases  with  severe 
headaches  and  distressing  insomnia  accompanied  by 
feelings  of  apprehension  and  nightmares  when  the 
patient  falls  asleep,  cannabis  indica  with  bromide  has 
been  exceedingly  useful,  but  should  be  used  with 
caution,  owing  to  its  somewhat  uncertainty  of  action. 
The  length  of  time  during  which  treatment  is 
necessary  varies  with  the  severity  of  the  case.  In 
60  per  cent,  of  the  cases  some  definite  improvement 
was  ahvays  noticeable. 

After  a  little  experience,  it  is  generally  possible 
after  a  few  days'  observation  to  pick  out  those 
patients  who  will  eventually  return  to  flying  under 


war  conditions  from  those  who  will  be  permanently 

No  patient  whom  the  medical  officer  considers 
permanently  unfit  for  any  further  flying  should  be 
sent  to  a  convalescent  home  where  there  are  other 
flying  officers  who  are  only  temporarily  unfit ;  in 
other  words,  a  permanently  unfit  officer  of  "  nervous 
type  "  is  a  source  of  danger  to  others  in  that  he 
"  infects  "  his  fellow-officers  with  his  own  troubles. 
He  is,  so  to  speak,  an  "  infectious  case,"  and  should 
be  removed  as  quickly  as  possible  from  the  other 
patients.  The  writer  has  known  two  or  three  in- 
stances where  one  patient  with  severe  neurasthenia 
was  sent  to  a  convalescent  home  and  appeared  to  be 
ultimately  responsible  for  the  "  breakdown  "  of 
several  other  patients  in  that  home.  In  short,  a 
patient  whom  the  doctor  considers  permanently 
unfit  for  any  further  flying  should  be  boarded  as 
soon  as  possible  (as  far  as  medical  circumstances 
will  permit)  and  marked  "  unfit  for  any  flying  duties  '* 
for  six  months.  The  relief  that  this  decision  affords 
to  the  patient  is  considerable,  and  the  writer  can 
give  sixteen  instances  of  patients  who  have  regained 
their  confidence  after  six  months'  complete  rest  from 
flying.  A  definite  decision  either  one  way  or  the 
other,  according  to  the  type  of  case,  has  a  very 
definite  "  therapeutic  "  value. 


At  the  present  moment  it  is  unfortunately  im- 
possible to  give  any  statement  of  much  value  on  the 
prognosis  of  the  cases  in  detail.  The  difficulty  of 
tracing  the  patients  is  great,  and  we  are  only  begin- 
ning to  discover  the  final  history  of  them. 

Consequently  the  question  of  prognosis  can  only 
be  discussed  on  the  broadest  basis. 

The    most    important    single    factor    in    prognosis 


is  : — the   length   of  sewice  and  the  amount   of  flying 
experience  obtained  before  the  breakdown  occurred. 

An  officer  who  has  badly  broken  down  after  a  few 
hours  in  France,  or  who  has  sustained  a  sHght  crash 
and  is  sent  home  soon  afterwards  as  unfit,  has  a 
poor  flying  future,  and  will  probably  be  best  advised 
to  give  up  flying.  AMiereas  the  officer  who  has  done 
a  great  deal  of  flying  and  who  has  had  a  very  full 
and  varied  experience  of  aerial  warfare  and  who 
breaks  down  late  in  his  flying  career  should  make 
an  ultimate  recovery  and  return  to  flying.  The 
shorter  the  flying  experience  the  worse  the  prognosis. 
The  longer  the  experience  the  better  the  prognosis. 
On  the  whole  there  is  no  better  prognostic  basis 
in  the  writer's  experience. 

Three  flying  accidents  have  a  very  adverse  bearing 
on  the  prognosis.     The  three  accidents  are  : — 

(1)  The  machine  catching  fire. 

(2)  A  breakage  in  the  air. 

(3)  A  direct  hit  by  anti-aircraft  fire. 

In  any  patient  w^ho  has  broken  down  and  who  has 
had  the  misfortune  to  experience  any  of  these,  the 
prognosis  is,  at  the  best,  uncertain. 

These  accidents,  the  most  dreaded  by  flying 
officers,  create  the  deepest  impression  on  the  mind. 
Personally  the  writer  has  not  seen  such  a  patient 
(whose  lot  it  was  to  be  involved  in  such  an  experience) 
regain  his  full  flying  confidence,  however  much  he 
improved  as  regards  simple  flying. 


The  conclusions  on  the  neurasthenia  of  war  flying 
from  a  practical  standpoint  (based  on  a  year's 
experience  and  necessarily  requiring  further  expan- 
sion and  modification  in  the  light  of  more  experience) 
are  as  follows  : — 

(1)  A  detailed  history  of  the  case  is  of  outstanding 


importance,  and  contains  the  key  to  the  subsequent 
treatment  and  prognosis. 

(2)  The  cases  fall  into  six  groups  : 

{a)  Simple  fatigue,  physical  and  mental,  as  the 
result  of  prolonged  stress  in  a  normal  individual. 

{h)  "  Neurasthenia,"  i.e.,  a  complex  group  of 
symptoms  and  signs  in  a  patient  who  has  lost  his 
flying  confidence  and  whose  personal  and  family 
history  are  not  entirely  satisfactory.  Such  a  patient 
will  show  evidence  of  a  general  nervous  instability, 
and  his  cortical,  bulbar,  and  medullary  centres  are  in 
a  condition  of  hyper-excitability  (as  is  shown  by  his 
symptoms  and  the  clinical  signs).  The  condition  in 
the  first  place  arises  from  a  mental  impression  and 
later  gives  rise  to  the  symptoms  and  signs  which 
are  found  on  examination.  He  has  lost  confidence 
in  flying  and  is,  therefore,  in  his  present  state,  useless 
as  a  flying  officer. 

(c)  This  class  comprises  those  flying  officers  who 
have  broken  down  through  some  toxic  factor  in 
their  history.  They  have  not  lost  their  flying 
confidence,  but  are  unfit  to  fly  until  this  toxic  factor 
is  removed.  When  they  are  well  they  return  to 
flying  with  unimpaired  confidence. 

{d)  Those  patients  termed  "  Psychopaths "  for 
want  of  a  better  word  are  unsatisfactory  for  all 
flying  service  except  under  very  special  conditions. 
They  are  assumed  to  be  suffering  from  a  disorder 
of  conduct,  and  as  a  rule  do  not  show  any  physical 
signs.  Their  family  history  is  generally  bad,  and 
their  upbringing  and  education  faulty. 

{e)  These  patients  have  not  lost  confidence  in  flying, 
but  are  unable  to  fly  at  high  altitudes  owing  to  symp- 
toms of  oxygen  want,  or  sickness  in  the  air,  etc. 
They  are  mentioned  in  this  article  since  their  symptoms 
may  be  wrongly  attributed  to  "  neurasthenia." 

(/)  Malingerers. 


(3)  Mixed  types  of  cases  are  common,  especially 
of  (b)  and  (c). 

(4)  All  patients  should  receive  a  thorough  exam- 
ination and  an  adequate  treatment,  and  should  not 
be  sent  away  on  leave  or  to  a  convalescent  home 
until  the  medical  officer  is  satisfied  that  no  further 
special  treatment  is  necessary. 

(5)  The  essence  of  prognosis  is  : — The  shorter  the 
flying  experience  the  worse  the  prognosis,  the  longer 
the  experience  the  better  the  prognosis.  In  such 
case,  the  most  important  patient  is  the  experienced 
officer,  and  every  effort  should  be  made  to  restore 
to  him  his  former  confidence. 

(6)  Hopeless  cases,  i.e.,  those  patients  who  appear 
permanently  unfit  for  further  service  should  never 
be  allowed  to  mix  with  cases  whose  breakdown  seems 
to  be  only  temporary.  They  should  be  discharged 
from  the  flying  service  as  soon  as  medical  circum- 
stances will  permit. 

The  writer  wishes  to  take  the  opportunity  of 
tliaiiking  Surgeon-General  Sir  Humphrey  Rolleston, 
K.C.B.,  for  much  valuable  criticism  in  the  writing 
of  this  article. 

It  is  gratifying  to  know  that  Surgeon  Gotch  has 
in  the  main  come  to  the  same  conclusions  as  the 
author  of  this  work  himself,  especially  as  to  the 
mental  or  central  origin  of  most  aero-neuroses  and 
also  as  to  the  prognosis  depending  on  the  time  of 
onset.  The  author  is  more  hopeful  of  getting  a 
flying  officer  back  to  duty  if  the  latter  has  already 
over  100  hours  to  his  credit.  During  the  last  year  the 
auth(jr  has  had  to  deal  with  surgical  cases  only,  either 
from  local  accidents  or  returned  wounded  from  over- 
seas, and  in  quite  a  number  of  these  one  of  the 
aero-neuroses  supervened,  but  many  got  over  the 
conditions  and  returned  to  flying  again. 


Aeroplane  Accidents 

In  the  early  days  of  flying  there  were  necessarily 
many  accidents,  owing  firstly  and  unfortunately  to 
structural  weakness  in  the  aeroplanes,  and  secondly 
to  the  fact  that  the  pioneer  pilots  had  to  experiment, 
and  were  mostly  unacquainted  with  many  of  the 
factors  governing  aerial  navigation.  When  man 
began  to  teach  man,  and  as  improvements  in  the 
construction  of  aeroplanes  increased,  so  accidents 
diminished  in  number  proportionately  ;  but  on  the 
other  hand,  many  more  took  up  flying,  and  the 
total  of  accidents  was  increased.  The  pre-war 
methods  of  teaching  were  slow  and  sure,  and  first 
solo  flights  were  made  in  stages  and  after  prolonged 
tuition,  thus  tending  almost  to  obviate  accidents 
altogether.  As  the  war  advanced,  and  the  import- 
ance of  aviation  was  recognised,  so  more  pilots 
were  required,  and  the  methods  of  teaching  had  to 
be  accelerated.  Thus  a  few  hours'  dual  control  in- 
struction— three  and  a  half  to  seven  hours — were 
given,  and  pupils  sent  off  to  do  their  first  solo  flights. 
Naturally  many  more  accidents  occurred,  and  as 
nowadays  tuition  is  on  faster  and  more  powerful 
aeroplanes,  so  have  the  total  number  of  accidents 
increased.  Every  accident  teaches  something  new, 
and  all  should  be  investigated  thoroughly,  so  that 
a  preventable  cause  or  error  can  be  eliminated  in 
the  future.  In  this  connection  the  reports  of  the 
Public  Safety  and  Accidents  Investigation  Committee 
of  the  Royal  Aero  Club  are  very  instructive  and 
should  be  studied. 

The  total  number  of  accidents  due  to  school  work 


Platk    I.     A  .seaplane  collided  with  ami  &luuk  lu   llic   ui 
a  large  wireless  station.     The  pilot  was  saved. 

Pr. \TE  2. — Prol)al)I\'  (lie  most  unique  aeroplane  accident  that  has  ever 


Plate  3.— An  aeroplane  cau;:lit   in   telegraph   wires-  la luletl  on  one 
wing  tip — occupants  uninjured. 

I'l-ATK  4.      A  IjiiidiiiL'  in  the  ti(c'to|i.«. 

1*LATE  .jA. — A  tuasli  ill  a  forest. 

I'r.xTK  ')}'..■    An  imitation  of  iiow  a  l)ir(l  lands  on  a  ticc-    pilot  uninjured. 


Plate  7. — A  l^elweeii  haiiiiars  sliowiiiii  (lilliiiili  ics  in  icai'hing 
the  injured  occu))ant. 


Platk  11. — An  unique  lauding — on  the  side  of  Dover  Castle. 



and  experimental  flying  is  greatly  augmented  by 
the  number  due  to  war  flying,  either  as  the  result  of 
aerial  duels  or  anti-aireraft  fire  from  the  ground. 

Classification  of  Aeroplane  Accidents 

An  attempt  has  been  made  to  elassify  accidents 
at  one  station  covering  a  period  of  six  months,  and 
these  are  referred  to  as  the  "  V  "  series.  In  a  general 
review  of  accidents  the  autlior  has  also  drawn  from 
fifteen  montlis'  experience  whilst  at  another  school, 

Fig.  1. — A  typical  crash — occupants  uninjured.      Aeroplane  has  to  l>e 
sent  into  workshop  for  repairs. 

and  these  are  referred  to  as  the  "  E  "  series.  In  the 
*'  V "  series  during  six  months  4,000  hours'  flying 
were  done,  consisting  of  9,000  flights  ;  and  during 
that  time  fifty-eight  aeroplanes  were  wrecked  or 
crashed.  The  suggested  definition  of  a  crash  is  an 
aeroplane  so  damaged  in  a  flying  accident  that  it 
has  to  be  deleted  or  sent  in  to  the  workshops  for 
repair  or  rebuilding.  (Fig.  1.)  This  is  in  contra- 
distinction to  the  effects  of  a  bad  landing  or  get 
off  where  the  ensuing  damage  is  small,  e.g.y  broken 



wires,  landing  wheel,  tail  skid,  or  bent  axle,  and 
can  be  repaired  by  the  flight  mechanics.  (Fig. 
2.)  Fifty-eight  crashes  in  9,000  flights  represent 
one  crash  in  every  155  flights.  In  these  fifty- 
eight  crashes  sixteen  were  injured,  which  is  equiva- 
lent  to   twenty-eight    being    injured    in    every    100 

iiG.   1'. — ^A   bad  landing — gentle  turn  over — occupanta  uninjured — 
landing  wheel  broken. 

crashes  ;  or  one  pupil  injured  in  every  560  flights. 
From  these  figures  one  can  see  that  school  flying 
is  fairly  safe  and  compares  favourably  with  other 
high  velocity  forms  of  transit.  In  the  table  which  the 
author  has  drawn  up  flying  accidents  have  been  classi- 
fied, firstly  with  regard  to  the  cause,  secondly  the  type 



or  in  which  part  of  the  flight  the  cause  was  initiated, 
thirdly  the  subtype  or  actual  damaging  cause,  e.g., 
the  ground,  trees,  houses,  other  aeroplane,  fire,  etc., 
and  fourthly  the  region  or  regions  injured.  To  each 
record  are  also  added  remarks  on  the  value  of  the 
safety-belt,  safety-helmet,  or  other  detail. 


V"  Series.     (1)  With  Injury  to  Pilot. 

No.  1  Number 


Type            Subtype            Kegion 


1  of  flight 



3rd     ... 

Loss  of  head 

Getting  off 

Collision  with 

Trunk    ... 

Belt  held. 





Collision  with 

Shoulder ; 



2nd    ... 

Loss  of  head 

Getting  off  Collision  with    Face 

Belt  gave  waj'. 



2nd    ... 

Brain  fatigue 


Collision  with 

Back      . . . 



1st      ... 



Collision  with 

Elbow  and 
foot    . . . 



ath     . . . 

Loss  of  head 

Getting  off 

Collision  with 

Back      ... 

Belt  held. 

ground           1 


2nd    ... 

Error  of  judg- 


Collision  with    Wrist     . . . 

Belt  gave  way. 




I2th  ... 

Loss  of  head 

In  the  air 

Collision  with 


Fatal  accident, 
belt  gave 


13  hours 

Error  of  judg- 


Collision  with 

Elbow   ... 

Belt  gave  way  : 
forced   land- 


12  hours 

Error  of  judg- 


Collision  w  ith 

Wiist     ... 

Belt  gave  way  i 
forced  land- 



Loss  of  head 

Getting  off 

Collision  with 


Belt  held. 


2nd    ... 

Brain  fatigue 


Collision  with 

Back      ... 

Belt  gave  way. 


2nd    ... 

Engine  defect 


CoUi.sion  with 

Neck  and 
back  ... 

Belt  held  : 
forced  land- 


7th     ... 

Loss  of  head 

In  the  air 

Collision  with 


Belt  gave  way. 


7th     ... 

Error  of  judg- 


Collision  with 


,,             ,, 


ground  :  fire 


(2)  Without  Injury  to  Pilot. 


Number  of 






1st      ... 

Error  of  judgment 


Collision  with  groimd 

Belt  held. 


(1st      ... 
tSrd     ... 

)>              » 


„              ,, 

Belt  gave  way. 


,,              „ 


>»              >> 

Belt  held. 


2nd    ... 

„              „ 


Collision  with  tree    . . . 



1st      ... 

Brain  fatigue 


Collision  with  groimd 



Ist      ... 

Loss  of  head 


j>              >» 



2nd    ... 

Error  of  judgment 




1st      ... 

j>              »> 





1st      ... 

„              „ 



Belt  gave  way. 


1st      ... 

,,              ,, 



Belt  held. 


3rd     ... 

„              „ 



Belt  gave  way. 


7th     ... 

j>              j> 



»          » 


7th     ... 

ti              >> 



>>          >» 


flOth  ... 
I20th  ... 

»>              » 



Belt  held. 


„              „ 



Belt  gave  way. 


,7th     ... 
il7th  ... 

?5                                    ?> 



Belt  held. 


>>                                    ?» 





12th  ... 

>>                                    5> 





7th     ... 





3rd     ... 

>>                                    »> 





4th     ... 


Getting  ofE 

Collision  in  air  with 
another  aeroplane 



1 5th     . . . 
i7th     ... 

Error  of  judgment 


Collision  with  groimd 

Belt  gave  way. 


,,              ,, 


,,              „ 

»>          »» 


,1st      ... 
isth     ... 

,,              ,, 




Belt  held. 


>>              j> 






4th     ... 






4th     ... 

„              „ 




Belt  gave  way. 


9th     ... 



Collision  in  air  with 
another  aeroplane 

Belt  held. 


,8th     ... 
i9th     ... 

Error  of  judgment 


CoUi^on  with  ground 

Belt  gave  way. 



>»          >» 


16th  ... 

..              ,. 



, 2nd    . . . 

i6th  .,. 

>.               ,. 

„              „ 

..          f. 


>>               >> 


>>              » 

Belt  held. 


After  10 


Getting  off 

Collision  with  tree    . . . 

Belt  gave  way. 



„               „ 


Collision  with  ground 

Belt  held. 



,,               ,, 


»)              »> 




j>               » 






>.               .. 

Getting  off 






,,               „ 







»               .. 








Getting  off 

Collision  with  aero- 
planes on  ground 






Collision  with  hidden 



2nd    ... 

Error  of  judgment 


Collision  with  ground 


*  Those  starred  and  bracketed  refer  to  the  same  pilot 



From  this  list  of 
table  and  chart  are 
of  crashes  on  earlv 

fifty-eight  crashes  the  following 
compiled  to  show  the  frequency 
solo  flights  : — 

Number  op  Crashes. 

Number  of 













After  10  hours 

Dual  con 



With  injury 
to  pilot 





Without  injury 
to  pilot 


















No.  of 

No.  of  Solo  Fli^t                                           1 


























f  \ 







— v 











The  above  chart  shows  a  greater  frequency  of 
crashes  on  the  first  and  second  solos,  then  a  diminu- 
tion from  the  third  to  the  sixtli  inehisive  and  a  rapid 
rise  again  on  the  seventh.  The  inference  suggested 
is  that  by  the  time  the  pupil  arrives  at  his  seventh 
solo  he  often  becomes  over-confident  and  a  little 



Causes  of  Aeroplane  Accidents 
The  causes  of  aeroplane  accidents  are  as  follows  : — 

(1)  Defect  in  the  aeroplane. 

(2)  Error  of  judgment  in  flying. 

(3)  Loss  of  head. 

(4)  Brain  fatigue  or  lethargy. 

(5)  Fear. 

(6)  Physical  illness. 

(7)  Unavoidable  causes. 

In  an  analysis  of  the  fifty-eight  crashes  in  the 
*'  V  "  series  the  following  table  shows  the  frequency 
of  these  causes  : — 

Number  of  Cbashes. 

With  injury 

Without  injurj 



to  pilot 

to  pilot 


(1)  Aeroplane  defect    . 




(a)  Breakage 

(b)  Engme  failure 

(2)  Error  of  judgment 




(3)  Loss  of  head 




(4)  Brain  fatigue 




(5)  Fear 




(6)  Physical  illness 




(7)  Unavoidable 








(1)  Defect  in  Aeroplane. — This  cause  amounts  to 
mechanical  failure  of  some  part  of  the  aeroplane, 
and  can  be  subdivided  into  (a)  breakage  in  the 
air,  and  {b)  engine  failure. 

(a)  In  the  early  days  of  aviation  breakage  or  giving 
way  in  the  air  of  some  vital  part  of  the  aeroplane, 
e.g.  the  folding  back  of  a  wing,  was  unfortunately 
fairly  common,  and  was  due  to  faulty  design  or 
weakness  in  construction.  Happily  to  a  great  extent 
this  has  been  corrected,  and  at  the  present  time 
very  few  accidents  are  due  to  this  cause.  In  three 
years'  experience  with  the  R.N.A.S.  the  author  has 


not  seen  a  machine  actually  break  in  the  air.  In  one 
case  in  the  "  E "  series  an  elevator  control  wire 
jammed  and  caused  the  aeroplane  to  nose-dive  ^vith 
fatal  results  to  both  occupants. 

(6)  Engine  failure,  yer  se,  may  be  a  direct  cause 
of  an  aeroplane  accident,  for  example,  if  the  engine 
fails  just  as  the  aeroplane  is  leaving  the  ground, 
and  there  is  unsuitable  landing  ground  and  obstacles 
in  front,  and  the  pilot  has  not  sufficient  height  or 
air  space  to  avoid  these.  Or,  for  example,  in  landing 
if  the  pilot  finds  in  his  glide  downwards  that  he  his 
undershot  or  overshot  the  mark,  and  his  engine 
will  not  "  pick  up  "  or  respond  to  carry  him  on  further 
to  suitable  landing  ground. 

On  the  other  hand  engine  failure  may  not  be  a 
direct  cause  but  may  be  a  strong  contributory  or 
indirect  cause  of  an  accident.  In  all  cases  if  the 
engine  fails  in  the  air  a  forced  landing  is  compulsor^^, 
but  given  a  fair  height — 2,000  feet  or  more — ^the 
pilot  can  usually  select  a  good  field  for  landing 
and  arrange  his  descent  accordingly.  Of  course  on 
approaching  the  field  to  land  it  may  be  foimd  not 
quite  so  good  as  was  imagined  from  a  greater  height, 
e.g.,  sloping  ground,  long  grass,  etc.,  and  thus  the 
pilot  may  make  an  error  of  judgment  on  actually 
landing.  This  quite  often  occurs  with  a  pupil 
but  rarely  with  an  experienced  aviator  who  knows 
exactly  how  to  "  pancake  "  his  machine.  But  even 
in  the  case  of  experienced  aviators,  engine  failure 
just  after  leaving  the  ground  is  a  strong  contributory 
cause  to  the  real  cause  of  an  accident,  namely,  an 
error  of  judgment  in  flying.  Authorities  cite  as 
one  of  the  commonest  examples  of  aeroplane  acci- 
dents, engine  failure  just  after  leaving  the  ground 
when  the  pilot  tries  to  turn  back  to  his  original 
starting  place,  loses  height  in  the  turning  and  in 
trying  to  prolong  Iiis  glide,  loses  flying   speed,  stalls 


— and  the  aeroplane  falls  to  the  ground  out  of 
control.  In  the  "  V  "  series  engine  failure  was  the 
direct  cause  in  one  case  and  was  a  contributory  cause 
in  two  cases. 

(2)  Error  of  Judgment. — Error  of  judgment  in 
flying  is  the  commonest  cause  of  aeroplane  accidents. 
This  error  may  occur  in  getting  off  the  ground,  in 
the  air,  or  on  landing.  Of  the  fifty-eight  crashes 
in  the  '  V  "  series  this  cause  accounted  for  forty- 
two — four  in  getting  off  the  ground,  and  thirty- 
eight  on  landing.  Of  the  many  examples  of  error  of 
judgment  in  flying,  perhaps  the  commonest  is  that 
in  which  the  pupil  in  landing  misjudges  his  distance 
from  the  ground,  and  either  "  flattens  out "  too 
soon  and  "  pancakes  "  with  a  crash,  the  occurrence 
of  which  depends  on  the  height  he  is  above  the  ground, 
or  else  "  flattens  out  "  too  late  and  strikes  the  ground 
at  a  varying  angle,  usually  over-turning  and  wrecking 
the  machine.  (Plate  12.)  Other  examples  of  errors  of 
judgment  in  the  air  are  putting  on  too  much  "bank'* 
with  insufficient  "  rudder  "  or  vice  versa  ;  climbing 
on  a  turn  ;  and,  as  in  engine  failure,  prolonging  a 
"  glide "  so  that  the  machine  loses  flying  speed. 
It  is  difficult  to  estimate  and  account  for  these 
errors  of  judgment.  In  some  cases  they  may  be  due 
to  insufficient  instruction.  In  other  cases,  even 
after  prolonged  instruction,  the  pupil  may  still  mis- 
judge distances,  and  on  examination  one  occa- 
sionally finds  that  his  standard  of  vision  is  below 
normal  ;  but,  on  the  other  hand,  the  pupil  may 
be  found  to  be  physically  fit,  to  have  normal  vision 
and  good  balancing  power.  In  the  latter  cases 
it  may  be  a  question  of  delayed  reaction  times, 
especially  the  visual  reaction  time  on  which  the 
aviator  is  so  much  dependent.  Normally  this  takes 
T^  or  Yob  of  a  second.  It  may  be  delayed  by 
fatigue,    drugs    and    excesses  ;     but,    on    the    other 

0       m 

Plate  12a. — Showint;  result  of   tlattenini;  out  too  late.      Aeroplane 
photograjihecl  ia  the  act  of  overturning — occupants  uninjured. 


I'l.ATi-;  Il'I!.     Showing  result  of  liatteiiiiig  oiil  loo  soon,  and  pancaking. 
L'ndercarriage  Itioken — occupants  uninjincd. 


hand,  in  some  individuals  who  are  otherwise  physi- 
cally fit,  it  is  found  to  be  much  slower  than 
normal,  so  that  it  is  evident  that  in  the  selection 
of  candidates  for  aviation  the  visual  and  other 
reaction  times  must  be  up  to  the  normal  standard. 
By  the  French  medical  authorities  on  aviation, 
candidates  are  rejected  if  the  reaction  times  are 
found  to  be  of  the  delayed  type. 

(3)  Loss  of  Head. — Loss  of  head  occurs  fairly 
frequently  in  a  greater  or  less  degree  and  accounts 
lor  a  fair  proportion  of  accidents — seven  in  the 
present  "  V  ''  series.  The  pupil  in  his  new  occupa- 
tion of  flying  for  the  first  time  has  all  his  mental 
faculties  on  the  alert  at  extreme  high  tension  ;  the 
sense  of  danger,  although  not  asserting  itself,  is 
ever  present  but  subconscious.  Under  the  sudden 
strain  of  an  emergency  the  power  to  reason  and  act 
synchronously  may  momentarily  lapse,  resulting 
in  what  is  known  as  loss  of  head.  In  a  critical 
position  the  pupil  has  to  think,  decide,  and  act  quickly ; 
but  in  loss  of  head  the  mental  balance  becomes 
upset — there  is  no  mental  inertia — so  that  the  wrong 
decision  is  taken  and  acted  on.  In  flying,  seconds 
and  parts  of  a  second  count  enormously  and  may 
mean  all  the  difference  between  safety  and  danger. 
After  actual  loss  of  head  there  is  seldom  time  to 
correct  the  error  made.  As  examples  of  loss  of 
head  in  the  air,  the  pupil  in  an  emergency  may  move 
the  throttle  the  wrong  way,  may  keep  his  engine 
full  on  when  he  should  throttle  down,  or  may  switch 
off  his  engine  at  a  moment  when  he  requires  all  the 
flying  speed  possible.  Loss  of  head  is  very  much 
allied  to  the  two  following  causes  of  accident,  brain 
fatigue  and  fear. 

(4)  Brain  Fatigue. — In  contradistinction  to  loss 
of  head  the  pupil  in  brain  fatigue  reaches  the  stage 
wlure  he   has  neither  the   power  to  reason,   decide 



nor  act.  A  state  of  mental  inertia  supervenes. 
This  is  due  to  repeated  stimuli  received  by  his 
brain  in  rapid  succession  in  his  flight ;  he  feels 
alone;  a  succession  of  errors  occurs  in  the  air;  he 
feels  he  cannot  manage  to  control  the  aeroplane  ; 
fear  does  not  seize  him,  but  the  enormity  of  the 
whole  thing  appals  him ;  he  feels  helpless  and  a 
state  of  brain  fatigue  occurs  in  which,  in  a  stupor,  he 
awaits  events  and  takes  little  part  in  the  aeroplane's 
control.  After  a  careful  study  of  100  of  the  first 
solo  flight  confessions  of  pupils,  and  of  many  pupils 
who  have  had  crashes,  whether  with  or  without  injury, 
the  author  is  convinced  that  brain  fatigue  is  a  cause 
of  a  fair  proportion  of  aeroplane  accidents.  Four 
occurred  in  the  fifty-eight  of  the  "  V  "  series.  As 
a  rule  in  brain  fatigue,  the  error  the  pupil  makes 
is  that  he  fails  to  flatten  out,  and  the  aeroplane 
strikes  the  ground  at  its  gliding  angle  and  becomes 
wrecked.  If  one  questions  a  suspected  case  of  brain 
fatigue  immediately  after  his  flight  one  finds  usually 
that  the  pupil  has  very  little  recollection  of  what 
he  did  in  his  flight.  Memory  seems  to  become 
partially  stunned.  It  is  difficult  to  make  a  diag- 
nosis of  those  liable  to  brain  fatigue.  As  a  rule, 
if  it  occurs,  the  pupil,  even  should  he  escape  injury, 
soon  gives  up  flying.  He  is  not  of  the  temperament 
suitable  for  flying.  As  a  preventive  the  pupil's 
first  few  solo  flights  should  always  be  of  short  dura- 

(5)  Fear. — Fear,  at  least  in  a  degree  sufficient 
to  disturb  one's  flying,  is  rarely  experienced  in  the 
air  on  the  first  few  solo  flights,  whatever  the  sensa- 
tions may  be  before  going  up  or  in  the  intervals 
between  flying.  The  mind  is  far  too  much  occupied 
and  concentrated  on  details  of  flying,  watching  the 
various  instruments  that  record  air  speed,  height, 
levels,  and  engine  revolutions,  and  in  judging  one's 


position  and  direction  in  the  air  relative  to  the 
ground.  From  an  analysis  of  the  confessions  of  the 
first  solo  flights  of  100  pupils,  and  of  his  own,  the 
author  notes  that  very  few  experience  fear  in  the 
air,  at  least  not  in  a  degree  sufficient  to  disturb 
one's  flying.  Many  confess  that  fear  is  subconscious 
— that  there  is  a  sense  of  danger  lurking  somewhere 
at  the  back  of  the  head,  but  that  it  rarely  if  ever 
asserts  itself.  In  the  "  V  "  scries  no  crash  occiu'red 
through  fear.  One  case  was  related  by  an  officer  in 
which  he  said  that  the  pilot  was  seen  in  the  air  to 
throw  up  his  hands  and  was  heard  to  shriek  ;  the 
machine  fell  out  of  control,  and  the  pilot  died  shortly 
afterwards  from  the  injuries  received. 

(6)  Pht/.sical  Illness. — In  the  series  of  crashes 
inider  consideration  none  was  attributable  to  physical 
illness.  At  an  air  station  medical  inspection  of 
the  pilots  and  pupils  at  regular  intervals  reveals 
any  organic  disease  that  might  lead  to  loss  of  con- 
sciousness in  the  air.  Flying  on  an  empty  stomacli 
may  cause  faintness  in  the  air.  In  schools,  flying 
begins  at  dawn,  and  all  pupils  are  provided 
with  a  good  meal  of  cocoa,  tea,  bread  and  butter. 
Similarly  on  long  flights  pilots  are  provided  mth 
tabloid  forms  of  nourishment.  The  effects  of  cold 
and  fatigue  may  produce  faintness  or  stupor  in  the 
air.  There  are  many  instances  on  record  of  pilots 
fainting  in  the  air  either  through  being  wounded  or 
from  high  altitude  effects.  Some  have  been  known 
to  recover  consciousness  before  reaching  the  ground 
and  have  been  able  to  make  successful  landings. 
Two  pupils  in  the  "  E  "  series  suffered  from  attacks 
of  malaria  in  the  air  and  both  were  made  to  dis- 
continue flying.  Another  pupil  in  "  E  "  series, 
although  slow  to  learn,  was  making  fair  progress, 
but  one  day  he  was  noticed  to  descend  rather  steeply  ; 
he   made  no  attempt  to   flatten  out,  the  aeroplane 


struck  the  ground  at  its  gliding  angle,  and  the  pilot 
was  thrown  out,  clear  of  the  machine,  a  distance  of 
66  feet,  and  escaped  with  only  a  slight  sprain  of 
one  ankle.  A  few  days  later  in  the  wardroom  this 
pupil  was  seized  with  a  series  of  typical  epileptic 
fits.  On  enquiry  a  history  of  epilepsy  for  the 
previous  five  years  was  elicited.  This  was  un- 
doubtedly a  case  of  an  epileptic  fit  taking  place  in 
the  air. 

(7)  Unavoidable  Causes. — From  time  to  time  un-» 
avoidable  causes  of  accidents  arise.  Every  precau- 
tion is  taken  at  a  flying  school  to  prevent  collisions 
in  the  air  or  on  the  ground.  Set  signals  are  made 
with  regard  to  the  direction  of  circuits  and  landing 
areas  for  different  flights.  The  terrain  in  certain 
areas  may  be  unsuitable  and  conceal  obstacles ; 
again,  in  some  aeroplanes  the  view  of  the  air  or 
ground  in  certain  positions  may  be  limited.  These 
conditions  may  cause  unavoidable  accidents.  In 
the  "  V  "  series  four  accidents  were  unavoidable — 
two  were  due  to  bad  terrain  with  obstacles  concealed 
in  the  grass^ — in  the  case  of  the  other  two  a  collision 
took  place  in  the  air.  One  machine  was  landing 
and  one  was  getting  off,  but  neither  saw  the  other, 
with  the  result  that  both  machines  collided  10  feet 
from  the  ground  and  were  wrecked,  but  both  pupils 
escaped  unhurt. 

Type  of  Accidents 

The  term  "  type  of  accident "  is  suggested  to 
describe  the  part  of  the  flight  in  which  the  cause 
of  the  accident  was  initiated.  It  is  possible  to  have 
an  arbitrary  division  of  a  flight  into  three  parts  : 
first,  the  getting  off  the  ground  into  the  air  up  to 
50  or  100  feet  ;  second,  in  the  air  with  the  various 
tiuns,  figures  of  eight,  climbs,  spirals,  etc.  ;  and, 
third,  the  landing,  which  includes  the  descent  from 


the  time  the  throttle  is  closed  to  the  time  the  aero- 
plane is  brought  to  a  standstill  on  the  ground. 

The  following  table  gives  an  analysis  of  the  types 
in  the  "  V  "  series  : — 

Number  of  Crashes. 

With  injury        Without  injury 
Type  of  accident  to  pilot  to  pilot  Total 

(1)  hi  getting  oif         . .  4         .  .  6         . .         10 

(2)  In  the  air    . .  . .  2         . .  0         .  .  2 

(3)  Li  landing  . .  . .  9         . .         37         . .         46 

Total         15         ..         43         ..         58 

Some  of  the  errors  whieh  the  pupil  may  make  in 
getting  off  are  raising  the  aeroplane's  tail  too  high, 
slueing  to  one  side,  or  getting  off  with  one  wing  down. 

In  the  air  a  pupil  may  lose  flying  speed  or  stall, 
or  may  sideslip,  or  spin. 

The  eommonest  type  of  aecident  is  in  landing, 
the  pupil's  hete  noire.  He  may  either  flatten  out 
too  soon,  lose  flying  speed  some  feet  from  the  ground, 
and  the  machine  "  pancake,"  or  else  he  may  be  too 
late  in  attempting  to  flatten  out,  and  the  aeroplane 
strikes  the  ground  at  an  angle,  turns  over  and  is 
wrecked.     (Fig.  3.) 

Scheme  for  First-Aid  at  an  Air  Station. 

The  Sick  Bay  or  Dressing  Station  should  be  in 
full  view  of  the  aerodrome,  with  a  lookout  man 
supplied  with  field  glasses  always  on  duty  during 
flying  hours.  Should  tlie  Dressing  Station  not  be 
situated  on  the  aerodrome,  the  former  should  be 
connected  by  telephone  to  the  lookout  man  whose 
position  commands  a  good  view  of  the  flying  area. 
Immediately  a  crash  or  forced  landing  occurs  the 
lookout  man  telephones  to  the  Sick  Bay,  notifying 
the  Steward  the  exact  site  of  its  occurrence.  A 
map  of  the  aerodrome  numbered  in  quadrants  can 
be    conveniently    arranged    in    the    Sick    Bay.     The 


lookout  man  then  leaves  his  post  and  proceeds  to 
the  scene  of  accident,  taking  the  hand  stretcher  on 
wheels,  on  which  is  carried  a  first-aid  dressing  bag 
and  an  emergency  tool  kit  case.  The  latter  con- 
sists of  an  oblong  box  containing  the  following  : — 

(1)  Two  crowbars.  (5)  A  hammer. 

(2)  Two  strong  wire  cutters.  (6)  Strong  cloth  cutting 

(3)  Saw.  scissors,  and 

(4)  A  long  stout  knife.  (7)  A  fire  extinguisher. 

Experience  of  aeroplane  accidents  teaches  one 
that  the  above  set  of  implements  is  very  necessary, 
as  in  some  crashes  where  the  pilot  is  pinned  under 
the  wreckage  it  may  be  difficult  to  reach  him.  In 
STich  eases  one  feels  helpless  without  these  emer- 
gency tools.  (Plate  13.)  An  injured  aviator  should 
never  be  dragged  out  of  a  crash  except  in  the 
case  of  fire,  but  rather  the  wrecked  machine  should 
be  cut  away  from  him.  In  many  cases  this 
prevents  simple  fractures  from  being  converted 
into  compound  ones.  (Plate  14.)  The  Steward 
on  being  notified  of  an  accident  despatches  the 
ambulance,  which  stands  always  in  readiness  by  the 
Sick  Bay,  to  the  scene  of  the  accident.  The  ambu- 
lance should  be  provided  with  twin  wheels  aft  in 
order  to  facilitate  movements  on  soft  earth,  etc. 
Two  sick  berth  attendants  go  with  the  ambulance 
and  with  them  is  a  bag  containing  the  following 
articles  : — 

(1)  Morphine  solution  and  two  Wildey's  hypodermic  syringes. 

(2)  A  bottle  of  chloroform  and  face  mask. 

(3)  Brandy. 

(4)  A  bottle  of  sterilized  water. 

(5)  Six  first-aid  field  dressings  and  shngs. 

(6)  Picric  acid  dressings. 

(7)  A  tourniquet,  cloth  cutting  scissors  and  a  knife. 

These  articles  can  easily  be  packed  into  a  small  bag 
10  in.  by  8  in.  by  3  in.  This  has  been  found  most 
useful  as  it  contains  all  that  is  necessary,  is  light, 

.  3'. 

Platk  13.— a  c-jisli  sli 

iiowiii'i  Dfcfssitv  of  liaviiiL'  omor<rencv  tool 
kit  to  cut  away  urcckaL'c  and  rcarli  (I,,,  injincd  aviators." 




can  be  easily  carried,  and  does  not  take  up  room 
if  one  has  to  go  by  air  to  an  accident.  The  surgeon 
on   duty   is   on   the   aerodrome   during   flying  hours 

luu.  .'i. — A  crash  ie.sult  of  tlatteniiif^  out  too  late. 
Machine  overturned  and  wrecked. 

and  proceeds  to  the  scene  of  the  accident  by  car  or 
foot.  If  the  accident  is  at  a  distance,  a  mile  or  more, 
it  is  Ijctter  to  go  by  aeroplane.  The  author  has  now  gone 


by  air  to  over  thirty  forced  landings  and  accidents 
at  a  distance  and  is  convinced  of  the  utility  of  this 
method  in  arriving  quickly  and  not  otherwise  tired 
and  out  of  breath  as  after  a  long  run.  In  connec- 
tion with  the  discovery  of  the  site  of  forced  landings 
and  accidents  at  a  distance  from  the  aerodrome 
much  depends  on  the  condition  of  the  country  around. 
Should  this  be  flat  country  these  accidents  are  fairly 
easily  discovered,  but  in  some  flying  schools  the 
surrounding  land  may  be  uneven,  intersected  with 
dykes  and  high  hedged  roads.  Thus  it  may  be 
extremely  difficult  for  the  search  party  to  find  the 
wreck.  The  author  suggests  under  these  conditions 
at  an  air  station  that  an  aeroplane  be  sent  up  and 
ordered,  on  discovery  of  the  crash,  to  circle  round 
it  ;  to  fire  a  Verey's  red  light  if  it  is  thought  that 
the  pilot  is  injured  ;  a  green  light  if  is  thought 
that  the  pilot  is  luiinjured  ;  and  a  white  light  to 
signify  that  it  is  possible  to  land  near  the  crash. 
Officers  and  flight  mechanics  who  arrive  or  are  sent 
out  to  the  scene  of  accident  should  be  trained  in 
first  aid  with  special  reference  to  aeroplane  accidents. 
Flying  pupils  should  not  be  alloAved  to  come  near 
or  help  unless  under   exceptional   circumstances. 

In  many  cases  the  crash  is  so  severe  that  the 
wreckage  has  to  be  cut  away  from  the  injured  aviator. 
In  other  cases  the  machine  is  upside  down  with  the 
pilot  held  head  downwards  by  his  safety  belt.  The 
latter  must  be  cut  and  the  pilot  slid  gently  out. 
The  emergency  tools  are  used  to  cut  wires,  remove 
wreckage  and  lever  away  the  heavy  parts,  e.g.,  the 
engine,  and  thus  easily  to  reach  the  injured  person. 
The  aeroplane  seat  cushion  is  taken  from  the  machine 
and  placed  under  the  injured  pilot's  head,  whilst 
his  body  rests  on  a  flying  coat  spread  out  on  the 
ground.  A  rapid  examination  is  carried  out  to 
determine    the    injuries    received.     If    the    injured 




person  is  conscious  and  in  much  pain  morphine  should 
be  injected  and  he  should  be  conveyed  quickly  to 
the  dressing  station,  where  clothes  can  be  cut 
away,  injuries  examined  and  treated.  If  un- 
conscious, some  cutting  away  of  clothing  can  be 
done  on  the  field,  injuries  examined,  and  perhaps  a 
dislocation  reduced  or  a  fracture  accurately  diag- 
nosed during  the  unconscious  period.  In  cases  of 
fire,  unless  the  pilot  is  thrown  clear,  the  fire  extin- 
guishers must  be  used  ;  but  if  there  is  any  wind 
blowing  they  are  of  little  use,  as  an  aeroplane  on 
fire  is  destroyed  completely  within  a  few  minutes. 
(Plates  15  and  16.)  The  pilot's  leather  clothing 
usually  protects  the  body  for  a  time,  but  the  face 
and  loAver  limbs  rarely  escape.  As  the  pain  is  very 
severe  (and  this  applies  to  other  injuries  apart  from 
those  caused  by  fire)  it  is  better  to  give  chloroform 
on  the  field,  and  this  administration  is  kept  up  on 
the  Avay  back  to  the  dressing  station.  Morphine 
sliould  also  be  given,  but  it  takes  some  time  to  act. 

Some  Factors  Relative  to  Aeroplane  Accidents 

The  injuries  sustained  are  akin  to  those  apt  to  be 
associated  with  most  high  velocity  accidents,  but 
are  usually  more  severe,  as  greater  speed  is  used 
in  aviation.  They  may  be  divided  into  :  (1)  In- 
juries due  to  crushing,  where  some  part  of  the 
pilot's  body  gets  crushed  between  parts  of  the 
wrecked  aeroplane,  e.g.,  between  the  engine  and  the 
woodwork,  or  between  different  parts  of  the  wood- 
work in  tractor  (engine  in  front)  types  of  machines ; 
(Fig.  4)  or  between  the  engine  and  the  earth, 
as  in  propeller  (engine  behind)  types  of  machines. 
Crushing  injuries  are  very  severe  in  nature  and 
mostly  fatal  in  the  latter  type  of  aeroplane.  (2) 
Injuries  due  to  collision  with  the  ground,  as  when 
the  pilot  is  thrown  out  or  hits  the  ground  with  his 

Plate  lo.-An  aeroplane  crashod  and  on  lire. 


head  in  turning  over  in  and  with  the  aeroplane. 
(3)  Injuries  due  to  impact  with  different  parts  of 
the  aeroplane,  as  when  the  head  is  violently  jerked 
forward  and  strikes  the  edge  of  the  nacelle  on  the 
aeroplane's  impact  with  the  ground.  (Fig.  5.)  Flying 
debris  such  as  broken  struts  and  wires  may  cause 
local   impact   injuries.     (4)     Injuries  from  fire.      (5) 

Fui.  5. — Showing  how  impact  injuries  occur.     Aviators  head  may  strike 
cockpit  edge  or  instrument  board. 

Drowning  and  immersion  effects  in  seaplane  work. 
(Fig.  6.)  And  (6)  suspension  effects,  as  when  the 
pilot  is  suspended  head  downwards  in  an  over- 
turned aeroplane  and  is  unable  to  loosen  his  safety 
belt.  (Fig.  7.)  In  many  crashes  the  sudden  impact 
of  the  pilot's  body  on  the  safety  belt  causes 
abdominal  injury. 

The     injuries     sustained    vary    a    good    deal    and 



depend  on  the  type  and  power  of  the  aeroplane, 
and  the  cause  and  type  of  accident  (see  classification). 
An  experience  of  three  years  attached  to  the  Royal 
Naval  Air  Service  has  impressed  the  author  more 
and  more  with  the  element  of  luck  in  crashes. 
The  present  day  school  aeroplane  is    much  stronger 

Iulj.  ♦>. — .Showing  lunv  druuiiiug  may  occur  us  result  oi  seaplane  crash 

in  construction  and  more  powerfully  engined 
than  in  earlier  days,  thus  providing  for  a  greater 
margin  of  error  on  the  pupil's  part.  The  propeller 
type  of  school  machine  (for  example,  the  Maurice- 
Farman)  is  considered  very  safe.  It  can  be  landed 
slowly  and  has  a  powerful  engine  to  cover  errors. 
In  a  crash  it  has  a  strong  under-carriage  and  a  great 
deal  of  woodwork  to  absorb  the  shock  before  actual 





injury  occurs  to  the  pilot.  On  the  other  hand,  in  a 
nose-dive  in  this  type  of  machine  the  engine,  being 
behind,  is  Hkely  to  crush  the  pilot  severely,  and  this 
usually  proves  fatal.  In  tractor  machines  the  engine 
in  front  takes  most  of  the  shock  in  a  crash,  but  the 

i}JQ.  8. — fcShowing  in  a  crash  in  a  tractor  machme  how  the  front  seat 
cock-pit  gets  crushed. 

observer's  seat  just  behind  the  engine  usually  gets 
telescoped  or  crumpled  sideways.  (Fig.  8.)  The 
pilot's  seat,  which  is  behind  these,  usually  escapes 
crushing  effects.  (Fig.  9.)  If  the  pilot  receives  injury, 
this  occurs  either  from  his  being  thrown  out  or  from 
his  head  being  violently  jerked  forward  and  hitting 
the  nacelle  edge,  wind-screen  or  instrument   board. 



Should  the  safety  belt  hold  the  sudden  impact  of  the 
pilot's  abdomen  and  lower  part  of  chest  against  it 
may  cause  internal  injuries.  Nowadays  most  nacelle 
edges  are  padded  and  safety  belts  are  stronger  and 

Safety  Belts. — With  regard  to  the  use  of  safety  belts 
endless  discussion  has  taken  place  amongst  aviators. 
The    author's    own    opinion   is   that    before   leaving 

I'lG.  y. — [Showing  how  the  pilot's  cockpit  escapes  crusiiing  ettect. 

the  ground  all  aviators  should  see  that  their  safety 
belts  are  fastened,  and  should  be  familiar  with  the 
method  of  their  quick  release.  The  belt  should 
never  be  undone  in  the  air.  Thus  the  pilot,  in  the 
event  of  fainting,  losing  consciousness,  or  being 
wounded,  or  encountering  gusty  and  bumpy  weatlier 
or  fog,  has  a  safeguard  to  prevent  him  either  being- 
thrown  out  in  the  air,  or  thrown  forward  on  to  his 
control  lever  (thus  causing  the  aeroplane  to  nose 
dive),  or  having  liis  feet  jerked  off  the  rudder  bar 
(thus  losing  steering  power).  All  probably  are  agreed 
on  the  above,  but  the  difficult  question  arises  whether 


to  release  the  belt  near  the  end  of  a  glide  before  land- 
ing. This  the  author  would  advise  in  the  propeller 
type  of  aeroplane,  but  in  the  tractor  machines  it 
remains  an  open  question,  as  the  following  figures  show. 
In  seventeen  crashes  on  tractor  machines  with  seven- 
teen injured,  the  belt  held  on  seven  occasions  and 
gave  way  in  ten.  In  forty-two  crashes  without 
injury  to  the  pilot  the  belt  held  in  two-thirds  of  the 
eases  and  gave  way  in  a  third. 

Aeroplane  Crashes — "  V  "  Series. 

Xumbor  of  injured  when  sriety  belt  held        .  .  .  .  7 

,,         uiiinjuied  when  safety  bolt  held    . .  .  .  28 

„         injured  A\hen  sr^fety  belt  gave  way  .  .  10 

„         uninjured  Avhen  safety  belt  gave  way  .  .  14 

Total  59 

Certainly  if  the  aeroplane  catches  fire  in  a  crash 
little  hope  can  be  entertained  of  the  pilot  if  he  be 
strapped  in.  Safety  for  him  depends  on  his  being 
thrown  out  clear  of  the  machine.  The  author  has 
seen  only  one  school  accident  where  fire  occurred,  and 
happily  the  belt  gave  way,  the  pilot  being  thrown  out 
and  sustaining  nothing  more  than  a  fractured  clavicle, 
whilst  the  aeroplane  was  destroyed  by  fire  in  less 
than  five  minutes.  (Fig.  10.)  A  narrow  belt  is 
to  be  condemned.  The  ideal  safety  belt  should 
be  broad  and  resilient,  attached  to  the  framework 
of  the  aeroplane  and  not  to  the  pilot's  seat, 
should  be  made  to  release  easily  and  quickly,  not 
at  the  centre  of  the  pilot's  body  but  at  the 
side,  where  it  is  attached  to  the  aeroplane.  This 
release  should  be  effected  by  oiieans  of  a  small 
hand  lever.  It  is  advisable  for  all  pilots  to  carry  a 
stout  knife  in  the  outside  pocket  of  their  flying  coat 
in  order  to  cut  the  belt  should  they  be  held  in  upside 
down  in  a  crash. 







Safety  Helmets. — Safety  helmets  are  of  un- 
doubted value  in  school  work  and  should  be  worn 
by  all  pupils.  They  should  fit  properly  and  not  be 
easily  dislodged  from  the  head  whilst  flying.  The 
modern  ones  are  much  lighter  and  less  high  in  the 
crown  than  the  earlier  ones  used.  In  a  crash  they 
certainly  prevent  scalp  wounds  from  broken  struts 
and  wires,  and  the  side  flaps  protect  the  ears  from 
injury.  Over  and  over  again  the  author  has  seen 
pilots  thrown  out  who  owe  their  escape  from  more 
or  less  serious  head  wounds,  to  their  safety  helmets. 

Cases  5,  7,  9,  12,  13,  14,  15,  22,  28,  30,  31,  32,  37, 
44  and  47,  were  certainly  saved  from  head  injury 
by  their  safety  helmets.  On  the  other  hand  in  a 
turn  over,  the  added  height  of  the  crown  may  catch 
the  ground  and  wrench  the  head  either  forwards 
or  backwards,  causing  fracture  dislocation  of  the 
neck  or  severe  strain  and  possible  rupture  of  the 
muscles  of  neck  and  back.  Case  13,  although  escap- 
ing head  injury,  had  his  head  violently  forced  forwards 
in  turning  over  and  sustained  severe  strain  of  the 
muscles  of  back  and  neck. 

As  pointed  out  by  Fleet  Surgeon  Wells,  an  ideal 
safety  helmet  would  take  its  support  from  the 

Goggles. — Most  aviators  wear  goggles  but  there 
are  still  some  who  prefer  to  fly  without  them.  The 
question  arises,  would  the  continuous  rush  of  air,  at 
from  50  to  120  miles  an  hour,  do  damage  to  the 
eyes  if  flying  were  carried  out  for  a  considerable 
length  of  time  without  goggles  ?  It  has  been  said 
that  as  the  air,  especially  at  flying  heights,  is  free 
from  dust  and  foreign  bodies  it  would  therefore  do  no 
harm  to  the  eyes.  The  author  knows  of  one  instructor 
who  after  a  year  continuously  instructing  pupils  and 
wearing  no  goggles,  began  to  suffer  from  a  form  of 
conjunctivitis.    He  certainly  thinks  that  goggles  should 




always  be  worn.  There  is  no  doubt  that  flying 
without  goggles  is  apt  to  set  up  a  spasm  in  the  eyes 
which  in  the  long  run  is  bound  to  do  harm.  Triplex 
or  non-splintering  material  is  now  almost  universally 
used  instead  of  glass  in  the  manufacture  of  aviation 
goggles.  Thus,  rarely  in  a  crash  do  we  get  any 
injury  to  tlie  eyes.  (Plates  IT  and  18.)  The  nose- 
piece  connecting  the  two  lunettes  should  have  no 
metal  in  its  composition.  He  has  seen  some  cases 
where  woimds  of  the  nose  were  caused  by  the  metal 
connecting  part  of  the  lunettes. 

Accidents  under  Dual  Control 

Accidents  imder  dual  control  are  not  common, 
as  the  instructor  has  usually  time  to  correct  in  the 
air  any  of  the  pupil's  errors  in  flying.  One  occurred 
in  the  "  V  "  series,  and  was  imavoidable  owing  to 
tlie  nature  of  the  ground.  In  the  "  E  "  series  three 
occurred.  One  was  due  to  defect  in  the  aeroplane 
whereby  the  elevator  control  wire  had  jammed, 
causing  the  aeroplane  to  nose-dive  and  resulting 
in  the  death  of  both  pupil  and  instructor.  A  second 
occurred  in  a  propeller  machine  where  the  pupil 
stalled  the  machine  at  forty  feet  from  the  ground, 
the  instructor  being  unable  to  correct  the  error  in 
time  ;  the  aeroplane  was  wrecked  and  the  instructor 
escaped  with  superficial  wounds  of  nose  and  chin, 
but  the  pupil  sustained  a  fracture  dislocation  out- 
ward of  right  ankle  ;  the  internal  malleolus  of  right 
tibia  was  fractured  and  also  the  fibula  in  two  places 
at  its  lower  and  upper  thirds.  X-rays  revealed 
fracture  of  the  os  calcis.  A  plating  operation  was 
carried  out,  and  the  pupil  returned  to  flying  eight 
months  afterwards  and  is  now  a  seaplane  pilot.  In 
tlu'  tliird  ease,  a  ))roj)eller  type  of  aeroplane  was 
stalled  thirty  feet  from  the  ground  and  was  wrecked  ; 
the    pupil    escaped     uninjured,    but    the    instructor 


sustained  a  lacerated  wound  of  the  knee  involving 
the  kneerjoint.  In  this  case  the  pupil  held  on  too 
firmly  to  the  control  lever.  All  dual  control  machines 
should  be  fitted  with  a  mechanical  device  for  throwing 
out  of  action  quickly  the  pupil's  control  of  the 
machine.  The  author  has  seen  three  other  crashes 
luider  dual  control  but  without  injury  to  either 
instructor  or  pupil. 

Fatal  Accidents 

In  two  years  of  school  work  the  author  has  only 
seen  three  fatal  accidents,  occurring  in  roughly  200 
crashes.  Four  deaths  occurred  of  which  three  were 
instantaneous  and  one  after  four  days.  All  were 
due  to  multiple  injuries.  The  foUoAving  are  short 
accounts  of  the  cases  : — 

Xo.  8.  "V"  Series.  R.  (R.F.C.).  In  a  tractor 
machine  on  landing,  this  officer,  when  50  feet  from 
the  ground,  lost  his  head  and  put  his  engine  full  on 
without  attempting  to  alter  the  glide.  The  aeroplane 
struck  the  ground  at  its  gliding  angle  with  engine 
full  on  and  was  completely  wrecked.  The  belt  gave 
way  and  the  pilot  was  thrown  out  but  death  was 
instantaneous  from  the  multiple  injuries  received. 
The  latter  consisted  of  :  (1)  Fracture  dislocation  of 
the  neck  ;  (2)  fracture  of  base  of  skull ;  (3)  fracture 
of  nose  ;  (4)  subglenoid  dislocation  of  right  shoulder 
and  (5)  multiple  abrasions.  This  officer's  vision 
was  I  in  each  eye  but  he  had  goggles  fitted  to  correct 
his  vision. 

"  E  "  Series. — In  a  propeller  machine  one  of  the 
elevator  wires  slipped  off  its  pulley  and  jammed, 
causing  the  aeroplane  to  nose  dive  from  200  feet.  ^ 
The  instructor  and  pupil  were  both  crushed  into  the 
earth  by  the  engine  and  death  was  instantaneous 
in  each  case.  ^Multiple  injuries  occurred  as  follows  : 
Instructor:     (1)  Fracture   dislocation    of   the   neck; 


(2)  iracture  of  the  nose  ;  {3)  fracture  of  first,  second, 
third,  and  fourth  ribs  on  left  side  ;  (4)  large  lacerated 
wound  of  left  side  of  chest  ;  (5)  lacerated  wound  of 
perineum  and  scrotum,  and  (6)  multiple  abrasions. 
Pupil  :  (1)  Fracture  of  base  of  skull ;  (2)  fractures 
of  lower  jaw  and  upper  jaw  of  right  side,  right 
radius,  first  metacarpal  of  right  hand,  lower  third  of 
right  femur,  lower  third  of  left  tibia  ;  (3)  lacerated 
woimds  of  face  and  right  eye,  and  of  posterior  aspect 
of  right  ankle  exposing  the  joint. 

"  E  "  series. — In  a  forced  landing  with  a  propeller 
machine  in  wooded  coimtry,  the  aeroplane  struck  a 
tree  and  was  wrecked.  The  instructor  sustained  a 
sub-glenoid  dislocation  of  the  left  shoulder,  but  the 
pupil  received  the  folloAving  injuries  :  (1)  Fracture 
of  base  of  skull ;  (2)  fracture  of  lower  third  of  left 
femur  ;  (3)  multiple  contusions  of  trunk  and  limbs. 
In  spite  of  a  decompression  operation  this  officer 
(hed  on  the  fourth  day. 

Regional  Injuries 

(1)  Multiple  Injuries. — These  usually  prove  fatal 
and  have  been  referred  to  under  fatal  accidents. 

(2)  Head  and  Neck. — Five  cases  of  head  and  neck 
injuries  occurred  in  the  "  V "  series,  and  three  in 
"  E  "  series.  The  following  are  short  accounts  of 
tlie  cases  : — 

(a)  "  V  "  Series,  No.  3.  C.  (U.X.A.S.),  aged  24. 
On  second  solo  in  a  tractor  machine,  stalled  on 
having  the  ground — lost  his  head  and  switched  off 
the  engine — machine  hit  the  ground  at  a  sharp  angle, 
turned  over  and  was  wrecked.  The  belt  gave  way 
and  the  pilot  was  thrown  out  and  rendered  un- 
conscious for  two  or  three  minutes.  He  sustained 
a  fracture  of  nose  witliout  displacement  and  showed 
concussion  symptoms  for  a  few  lioiu's.  Subcon- 
junctival haemorrhage  appeared  next  day,  but  other- 


wise  the  case  did  well  and  left  hospital  in  a  fortnight. 
On  examination  at  that  date  insomnia,  headaches, 
nightmares,  and  loss  of  confidence  in  flying  were 
present.  The  fracture  had  healed  but  the  knee-jerks 
were  increased.  Two  months'  leave  was  granted 
away  from  all  connection  with  aviation.  Two  months 
later  the  same  signs  and  symptoms  were  present 
and  as  his  confidence  had  not  returned  he  gave  up 
aviation — diagnosis    "  aero-neurosis." 

(b)  "V"  Scries,  No.  2.  C.  (R.N.A.S.),  aged  18. 
As  a  pupil  receiving  instructioUj  this  officer  had  a 
crash  with  his  instructor  in  a  tractor  machine  whilst 
making  landing  practice.  The  aeroplane  hit  a  small 
tree  and  overturned.  The  belt  held,  but  the  pupil 
sustained  a  fracture  of  the  nose  from  a  broken  strut, 
and  also  a  triangular  shaped  wound  under  the  right 
eye  and  a  wound  of  forehead.  In  hospital  three 
weeks  and  then  sent  on  leave. 

(c)  "V"  Series,  No.  11.  C.  (R.N.A.S.),  aged  21. 
Made  a  bad  landing  on  his  seventh  solo,  lost  his  head 
and  put  the  engine  full  on  to  go  up  again — saw  he 
was  unable  to  clear  the  trees  so  shut  off  engine  and 
awaited  events.  The  aeroplane  was  wrecked- — the 
belt  held  but  the  pilot's  head  was  jerked  forward 
and  struck  the  nacelle  edge — the  back  of  the  head 
also  receiving  injury  from  broken  strut.  Severe 
contusion  of  forehead,  with  abrasions  of  left  side  of 
face,  and  contusion  of  right  lower  posterior  parietal 
region  were  sustained.  There  was  no  surgical  shock 
or  cerebral  injury.  In  hospital  for  fourteen  days, 
then  returned  to  flying,  was  given  instruction  on  a 
slow  type  of  machine,  but  as  progress  was  slow  he 
was  transferred  to  another  flving  school. 

{d)  "  V  "  Series,  No.  14.  'S.  (R.N.A.S.),  aged  20. 
On  seventh  solo  when  gliding  down  to  land  stalled 
at  200  feet,  side-slipping  and  wrecking  aeroplane. 
The  cause,  loss  of  head,  was  initiated  in  the  air.     The 


belt  gave  way  and  pilot  was  found  stunned  amongst 
the  wreckage.  Contusions  and  abrasions  of  chin  and 
nose  and  of  left  hand  were  sustained.  In  hospital 
one  week,  but  this  officer  was  advised  to  give  up 

(e)  "  V  "  Series,  No.  13.  C.  (R.N.A.S.),  aged  26. 
On  second  solo — engine  failure  caused  a  forced  land- 
ing— when  100  feet  from  the  ground  white  smoke  was 
emitted  from  tlie  engine  clouding  the  pilot's  vision 
and  obscuring  his  view  of  the  ground  so  that  he  was 
unable  to  flatten  out.  The  machine  was  turned  over 
and  wrecked,  the  belt  held  but  pilot's  head  was 
forcibly  jerked  forward  in  the  turn  over.  The 
safety  helmet  saved  scalp  injury.  Pilot  walked  into 
camp  from  the  wreck,  a  distance  of  two  miles.  In 
hospital  five  weeks  with  severe  strain  of  muscles  of 
l)ack  and  neck.  X-rays  revealed  no  fracture,  but 
there  was  great  tenderness  over  the  region  of  the 
fourth  and  fifth  cervical  vertebrae ;  the  knee-jerks 
were  greatly  increased.  Was  sent  on  leave  for  six 
weeks  and  had  massage  to  neck  daily.  He  has 
now  returned  here  to  flying  ;  the  knee-jerks  are  still 
greatly  increased  but  there  is  no  evidence  of  aero- 

(/)  "E"  Series.  N.  (R.N.A.S.).  An  instructor. 
Failed  to  correct  a  pupil's  error  in  the  air ;  the 
aeroplane  was  stalled  and  side-slipped  from  40  feet. 
Instructor  received  wounds  of  nose  and  chin,  but 
resumed  flying  a  week  later. 

ig)  "  E "  Series.  D.  (R.N.A.S.).  Got  off  the 
ground  in  a  tractor  machine  with  one  wing  down,  this 
increased  till  the  machine  side-slipped  and  was 
wrecked.  Tlie  belt  held  l)ut  pilot's  head  was  jerked 
forward  and  hit  tlie  nacelle  edge,  he  sustained 
superficial  woiuids  of  nose  and  left  cheek.  This 
ofiieer  continued  to  fly  in  three  weeks'  time. 

{h)  "E"    Scries.     F.    (R.N.A.S.).     In    a    tractor 


machine  climbing  on  a  turn,  lost  speed,  and  nose- 
dived from  100  feet.  Pilot  got  out  of  the  wreckage 
unassisted  but  fainted  immediately  afterwards.  He 
sustained  an  incised  wound  from  one  canthus  to  the 
other,  exposing  nasal  bones,  which  were  uninjured,  a 
lacerated  wound  1  inch  long  of  left  eyebrow  and 
eyelid,  and  a  wound  1  inch  long  of  conjunctiva  of 
left  eye.  Eyeball  at  the  time  apparently  uninjured 
and  vision  unimpaired.  Later,  haemorrhage  occurred 
into  the  anterior  chamber  with  some  retinitis  pro- 
duced by  concussion  of  eyeball.  This  gradually 
cleared  up  and  in  two  months'  time  vision  was 
I  in  each  eye.  However,  there  was  a  great  deal  of 
scarring  of  the  wounds  of  eyelid  and  nose.  Fibrolysin 
and  radium  treatment  were  carried  out. 

None  of  these  injuries  proved  fatal.  Five  con- 
tinued flying,  and  three  gave  up.  In  three  of  these 
cases  the  injuries  were  caused  by  the  head  being 
violently  jerked  forward  and  striking  the  nacelle 
edge  ;  three  were  caused  by  the  head  striking  the 
groimd,  and  two  were  caused  by  broken  struts. 

(3)  Trunk. — Five  occurred  in  the  "  V "  series 
and  none  in  the  "  E  "  series  : — 

{a)  "V"  Series,  No.  4.  MeK.  (R.X.A.S.),  aged 
21.  On  second  solo  ;  had  flown  very  badly  for  some 
twenty  minutes  ;  in  landing  failed  to  flatten  out ; 
hit  at  gliding  angle  ;  belt  broke  and  pilot  was  thrown 
20  feet  and  sustained  injury  to  mid-dorsal  spine. 
The  cause  was  undoubtedly  brain  fatigue  or  lethargy. 
X-rays  revealed  telescoping  of  sixth  into  seventh 
thoracic  vertebrae,  and  a  sub-luxation  of  sixth  right 
rib  at  its  vertebral  end.  There  was  no  injury  to 
spinal  cord  ;  movements,  sensations  and  reflexes 
of  lower  limbs  being  undisturbed.  Surgical  shock 
was  very  marked  and  lasted  forty-eight  hours. 
Treatment  consisted  in  lying  flat  in  a  spinal  bed  splint 
for  three  months.     Then  a  spinal  jacket  was  fitted 


and  patient  allowed  to  move  about.  At  present 
this  case  is  doing  well.  There  is  some  general 
kyphosis  in  mid-thoracic  spine  and  also  some  limita- 
tion of  spinal  movement  in  that  region.  At  present 
in  hospital  but  will  probablv  be  able  to  flv  again. 

(b)  "  V  "  Series,  No.  6.  'A.  (R.X.A.S.);  aged  18. 
On  fifth  solo  ;  got  off  the  ground  with  one  wing 
down  and  climbing  ;  when  oO  feet  up  shut  off  engine 
through  loss  of  head  and  side-slipped  to  the  ground. 
The  machine  overtm-ned  and  pilot  was  crushed, 
but  the  belt  held.  He  sustained  a  large  contusion 
around  left  eye  but  no  injury  to  eyeball  except  some 
sub-con  junctival  haemorrhage,  vision  unimpaired. 
Strain  of  upper  part  of  abdomen  with  a  belt  of 
hypericsthesia  over  epigastrium.  Injury  to  mid- 
thoracic  spine  which  an  X-ray  examination  proved 
to  be  a  fracture  of  the  body  of  seventh  thoracic 
vertebra  but  with  no  injury  to  spinal  cord.  There 
was  severe  surgical  shock  and  a  great  deal  of  pain, 
the  shock  passed  off  in  forty-eight  hours,  but  the 
pain  continued  for  two  weeks.  The  area  of  hyper- 
aesthesia  cleared  up  in  five  weeks'  time.  Treatment  : 
flat  on  back  for  three  months,  then  a  spinal  jacket 
was  fitted.  It  is  not  likely  that  this  officer  will  fly 
again.  There  is  marked  kyphosis  with  a  boss  over 
the  seventh  thoracic  spinous  process. 

It  is  curious  that  the  above  two  cases  both  had 
fracture  of  the  seventh  thoracic  vertebra,  in  both 
cases  of  a  telescoping  nature  :  in  (a)  the  one  centrum 
evenly  telescoped  into  its  neighbour,  and  in  (b)  the 
one  centrum  imevcnly  and  partially  telescoped  into 
the  one  below.  In  both  cases  also  the  spinal  cord 
escaped  injury. 

(c)  "V"  Scries,  No.  12.  B.  (R.F.C.),  aged  20. 
On  second  solo.  Pilot  remembers  commencing  the 
glide  to  land  from  1000  feet  but  can  remember 
nothing  more   of  the   accident.     lie   was   physically 


fit  before  flying  and  there  is  no  evidence  to  show 
that  he  fainted  in  air.  It  is  probable  that  he  suffered 
from  brain  fatigue  and  was  unable  to  think  quiekly 
enough  to  flatten  out.  Machine  was  wrecked  : 
belt  gave  way  and  pilot  was  found  in  the  wreckage. 
Loss  of  consciousness  for  five  minutes  followed  by  a 
degree  of  surgical  shock.  There  was  a  severe  strain 
of  muscles  of  back,  but  X-rays  revealed  no  fracture. 
There  was  a  contusion  of  lower  part  of  chest  and 
upper  part  of  abdomen  due  to  impact  on  safety-belt ; 
abrasions  of  nose,  lips  and  chin.  He  improved  under 
rest  and  massage,  but  is  not  likely  to  re-continue 

[d)  "  V "  Series,  No.  2.  S.  (R.F.C.),  aged  26. 
AVhilst  instructing  a  pupil  in  landing  practice,  owing 
to  an  unavoidable  cause  overturned  and  wrecked  the 
machine.  He  sustained  a  contusion  of  right  side 
and  back  of  chest,  sprain  of  right  shoulder  and 
abrasion  of  right  knee.  There  was  slight  haemoptysis 
which  ceased  after  admittance  to  hospital.  Under 
rest,  massage  and  movement,  this  case  did  well  and 
in  a  few  weeks  returned  to  flying  duties. 

{e)  "V"  Series,  No.  1.  M.  (R.F.C.),  aged  27. 
When  getting  off  on  his  tliird  solo  lost  his  head  and 
put  the  machine's  nose  down  to  earth  with  engine 
full  on.  The  machine  overturned  and  was  wrecked. 
The  safety  belt  held  but  the  impact  of  the  pilot's 
body  caused  compression  of  lower  part  of  chest  with 
severe  dyspnoea  which  lasted  for  about  two  hours. 
No  evidence  of  fracture  of  ribs,  but  pilot  sustained  a 
severe  sprain  of  left  shoulder.  Uneventful  recovery. 
Granted  three  months'  leave. 

Of  these  five  cases,  one  is  still  flying  ;  one  gave 
up  ;  one's  subsequent  history  unknown  ;  and  two 
are  in  hospital,  of  which  one  will  probably  be  unable 
to  take  up  flying  again,  and  the  other  may  probably 
re-continue  flying. 


Injury  to  the  trunk  occurs  from  crushing  effect 
between  different  parts  of  the  wrecked  aeroplane, 
or  between  the  wreck  and  the  groinid.  It  is  curious 
that  more  severe  injuries  did  not  occur. 

It  has  been  noted  that  sudden  chest  and  upper 
abdomen  compression  can  occur  from  the  sudden 
impact  on  and  tightening  of  the  safety-belt  around 
the  pilot's  body  in  a  bad  crash  ;  dyspnoea,  rigidity 
of  muscles,  tenderness  and  hyperaesthesia,  are 
amongst  the  ensuing  symptoms  from  this  cause. 

(4)  Upper  and  Lozver  Extremities. — Five  occiu-red 
in  the  "  V  "  series,  and  four  in  the  "  E  "  series.  Six 
with  injury  to  the  upper  extremity,  and  three  to  the 
lower  extrcmitv  : — 

(a)  "V"  Series,  No.  5.  K.  (R.F.C.),  aged  18. 
On  his  first  solo  flight  saw  another  machine  crash 
on  the  ground  beneath  him.  In  coming  down  to 
land  this  crash  seemed  to  hypnotise  him  and  he 
failed  to  flatten  out.  Machine  turned  over  and  was 
wrecked.  Belt  broke  and  pilot  Avas  thrown  out  a 
distance  of  30  feet.  He  sustained  a  backward 
dislocation  of  right  elbow  and  an  inward  dislocation 
of  left  foot.  Unconscious  for  five  minutes,  followed 
by  severe  cerebral  irritation  which  lasted  for  half 
an  hour.  The  dislocations  were  easily  reduced. 
This  officer  returned  to  flying  duty  in  three  months' 

{b)  "V"  Series,  No.  7.  N.  (R.F.C.),  aged  19. 
On  liis  second  solo  through  error  of  judgment  did 
not  flatten  out  soon  enough.  Belt  broke  and  pilot 
was  thrown  out.  He  sustained  an  impacted  fracture 
of  lower  end  of  riglit  radius  with  broadening  of  wrist 
but  no  antero-posterior  displacement.  Some  pain 
and  rigidity  over  upper  part  of  abdomen  from  impact 
on  belt.  This  case  did  well  under  massage  and  move- 
ment and  returned  to  flying  six  weeks  later. 

(c)  "V"    Series,    No.    9.     W.    (R.F.C.),    aged    19. 


This  officer  had  done  thh'teen  hours'  flying.  On  a 
forced  landing  came  down  on  ploughed  land  and  did 
not  flatten  out  soon  enough  through  error  of  judg- 
ment. The  machine  overturned.  Belt  broke  and 
pilot  was  thrown  out,  sustaining  a  severe  sprain  of 
left  elbow.  There  was  considerable  pain,  swelling, 
and  limitation  of  movement,  but  these  rapidly  dis- 
appeared under  massage  and  movement.  This  officer 
returned  to  flying  in  three  weeks'  time. 

(d)  "  V "  Series,  No.  10.  H.  (R.F.C.),  aged  27. 
This  officer  had  done  twelve  hours'  solo  flying.  On 
a  forced  landing  on  ploughed  land  failed  to  flatten 
out  enough  through  error  of  judgment.  The  machine 
overtiu'ned.  Belt  broke  and  pilot  was  thrown  out 
sustaining  an  injury  to  riglit  wrist.  X-ray  examina- 
tion revealed  no  fracture.  This  case  did  well  and 
returned  to  flving  in  three  weeks. 

(e)  "  V "  Series,  No.  15.  N.  (R.F.C.),  aged  19. 
On  his  seventh  solo.  Had  just  got  off  the  ground 
when  he  saw  two  aeroplanes  crossing  his  path.  He 
pulled  back  the  control  lever  to  clear  the  other 
machines,  but  stalled  and  side-slipped,  striking  the 
ground  with  engine  full  on.  Belt  broke  and  pilot 
was  thrown  out  clear  of  the  machine  which  immed- 
iately burst  into  flames  and  was  rapidly  destroyed 
by  fire.  Pilot  was  unconscious  for  five  minutes 
and  sustained  a  fracture  of  left  clavicle  at  junction 
of  middle  and  outer  thirds.  Treatment  consisted 
in  allowing  the  injured  arm  to  hang  over  the  bed 
with  a  pillow  between  shoulders. 

(/)  "  E  "  Series.  J.  (R.N.A.S.),  aged  26.  On  a 
cross-country  flight  had  engine  failure,  had  to  do  a 
vertical  bank  low  down  to  avoid  some  trees  ;  one 
wing  tip  hit  a  tree  and  aeroplane  was  badly  wrecked. 
This  officer  sustained  a  subglenoid  dislocation  of  left 
shoulder  and  a  wound  2  inches  long  underneath  lower 
lip  and  penetrating  the  mouth  ;    an  incised  wound 


under  chin,  with  severe  bruises  of  both  arms  and 
legs.  Unconscious  for  three-quarters  of  an  hour 
but  idtimately  did  well  and  returned  to  flying  in 
six  months'  time. 

ig)  "  E  "  Series.  W.  (R.X.A.S.),  aged  24.  This 
pupil  whilst  imder  instruction  on  a  dual  control 
propeller  machine  stalled  through  an  error  in  judg- 
ment and  machine  side-slipped  from  40  feet  and 
was  wrecked.  He  sustained  a  fracture  dislocation 
outward  of  right  ankle  ;  the  internal  malleolus  of 
tibia,  and  the  upper  and  lower  thirds  of  fibula  were 
fractured.  A  plating  operation  was  performed  a 
month  later.  This  officer  returned  to  duty  in  six 
months  and  is  now  a  seaplane  pilot.  Ultimately 
good  movement  was  obtained  in  the  ankle-joint, 
although  a  weakness  occurred  after  prolonged  walking 
or   exercise. 

(h)  "E"  Series.  L.  (R.X.A.S.),  aged  18.  In  a 
propeller  machine  on  first  solo  overbanked  on  his 
first  turn,  the  machine  stalled  and  side-slipped  200 
feet  to  earth.  Pilot  was  found  in  the  wreckage  and 
sustained  a  simple  fracture  of  middle  third  of  right 
femur  with  2  inches  of  shortening  ;  there  were  abra- 
sions of  left  leg,  right  forearm,  forehead  and  chin. 
Superficial  wounds  of  right  eyebrow  and  bridge  of 
nose.  Siu'gical  shock  was  severe.  The  fracture 
was  set  and  retained  in  position  by  means  of  a  traction 
splint,  and  a  good  result  was  obtained.  This  officer 
returned  to  flving  in  eight  months'  time. 

(i)  "E"  Series.  E.  (R.N.A.S.).  An  instructor, 
giving  dual  control  instruction  to  a  pupil,  had  just 
left  the  ground  when  the  control  lever  jammed  or 
was  held  too  tightly  by  the  pupil,  causing  the  machine 
to  stall  when  40  feet  from  the  ground  and  side- 
slipped to  earth.  The  pupil  escaped  unhurt,  but 
the  instructor  sustained  a  lacerated  wound  5  inches 
long  over  th(;  right  knee,  exposing  the  patella  and 


penetrating  knee-joint.  The  belt  held  but  the  front 
of  the  nacelle  was  crushed  in ;  impact  with  the 
instrument  board  had  caused  the  wound.  The  case 
did  well  and  returned  to  flying  within  five  months. 

Of  these  cases  eight  have  returned  to  flying  duties, 
and  one  is  still  under  treatment.  The  usual  cause  of 
injuries  to  the  upper  extremities  in  crashes  is  due 
to  the  pilot  being  thrown  out.  Usually  a  hand  is 
thrown  out  as  a  safeguard  and  injury  to  the  upper 
arm  ensues.  In  six  of  these  cases  the  safety  belt 
gave  way  and  the  pilots  were  thrown  out,  all  sustain- 
ing injury  to  the  arm  ;  in  the  three  other  cases  the 
pilots  were  not  thrown  out  but  all  sustained  injury 
to  the  leg.  It  is  safer  not  to  drag  the  injured  aviator 
out  of  the  wreck  but  rather  to  cut  the  wreckage 
away  from  him.  In  three  of  the  cases  engine  failure 
and  subsequent  forced  landing  was  a  contributory 
cause  of  the  accidents. 

The  author  trusts  that  the  scheme  which  he 
has  outlined  for  the  classification  of  aeroplane 
accidents  will  be  taken  up  and  improved  by 
other  medical  officers  attached  to  air  stations.  It 
is  only  by  having  a  large  number  of  reports  that 
reliable  statistics  can  be  obtained. 

There  is  no  doubt  that  much  can  be  done  to  pre- 
vent loss  of  life  in  flying  accidents,  and  also  to 
minimise  the  severity  of  injuries  sustained  both  in 
school  and  active  service  flying.  The  means  of 
saving  life  is  by  parachute  descent  ;  but  it  is  essen- 
tial that  the  parachute  be  carried  so  arranged  that 
when  required  it  can  be  liberated  from  the  aeroplane 
without  fear  of  entanglement,  and  also  that  it  will 
open  fairly  quickly.  Lately  on  the  western  front 
several  instances  have  been  reported  of  successful 
parachute  descents  by  enemy  aviators  from  aero- 
planes either  set  on  fire  in  the  air  or  so  damaged  by 
gun  fire  as  to  be  uncontrollable. 


By  some  device  during  the  aeroplane's  descent  the 
parachute  is  hberated  and  forcibly  draws  the  attached 
aviator  from  his  seat  clear  of  the  damaged  and 
falling  aeroplane.  The  use  of  the  parachute  is 
more  essential  for  war  flying  than  for  school  flying. 
In  the  former,  machines  are  more  often  damaged 
in  the  air,  and  there  may  be  both  time  and  height 
to  escape  by  parachute.  While  in  the  latter,  most 
accidents  occur  on  landing  or  leaving  the  ground, 
and  the  causes  are  initiated  a  few  seconds  before 
so  that  there  would  neither  be  time  nor  height 
to  escape  by  parachute.  xA.lthough  it  is  quite 
possible  a  proportion  of  school  accidents  might  occur 
in  the  air,  such  as  fire  or  breakage,  etc.,  and  that  there 
would  be  both  time  and  height  to  escape  by  para- 
chute. Probably  the  difficulties  of  attachment  and 
design  may  be  overcome,  so  that  in  the  future  all 
aeroplanes,  whether  employed  for  tuition,  commerce 
or  war,  will  carry  parachutes. 

In  quite  a  large  proportion  of  aeroplane  accidents 
the  occupants  receive  injuries  to  the  face,  due  to  the 
impact  throwing  their  heads  forward.  Thus  the 
face  may  strike  the  edge  of  cockpit  or  nacelle,  gun 
mounting  or  instrument  board,  resulting  in  fracture 
of  skull,  nose,  upper  or  lower  jaw,  or  else  severe 
wounds  of  face  with  subsequent  disfigiu*ement. 
Death  may  ensue  from  such  injuries,  or  they  may 
disable  tlie  aviator  for  some  considerable  time. 
A  fractured  lower  jaw  means  at  least  eight  months 
bef(n'e  return  to  flying  duties.  The  eyes  fortunately 
usually  escape  injmy,  as  apart  from  natural  ])ony 
))rotection  tliey  are  usually  closed  in  by  non-splinter- 
ing material  such  as  Triplex.  The  edges  of  the 
cockpit  are  usually  padded  in  most  modern  machines 
and  gun  mountings  are  ])laeed  laterally.  There  is 
no  reason  why  a  padded  face  piece  should  not  be 
added  to  the  safety  helmet. 



There  is  a  natural  disposition  on  the  part  of  most 
pilots  to  feel  they  want  to  be  free  and  unimpeded 
whilst  flying.  In  the  old  days  many  used  to  scoff 
at  goggles,  safety  helmets  or  belts  ;  but  at  present 
most  aviators  realise  the  value  of  these  things,  and 

Fic.  11. — iShovving  the  aeroplanes  nose  striking  the  ground  first,  and 
how  the  aviator's  feet  and  legs  are  likely  to  be  injured. 

are  more  inclined  to  welcome  the  investigations  of 
medical  officers  concerning  aeroplane  crashes  and 
adopt  their  suggestions  of  apparatus  and  methods 
for  preventing  or  minimising  bodily  injuries.  As 
the  forepart  of  the  aeroplane  usually  strikes  the 
ground  first,  it  follows  that  should  the  occupant  not 

Tlate  19a.— a  fatal  crash. 

Plate  1!)b.    -Result  of  a  collision  in  (ho  air. 



be  thrown  out,  bis  feet  and  lower  legs  are  most 
likely  to  sustain  injury.  (Fig.  11.)  Fractures  of 
both  bones  of  leg  and  those  involving  ankle  joint  are 
very  common.  The  author  would  suggest  that  double 
light  steel  supports  fitted  in  the  boots  and  carried  to 
just  below  the  knee,  as  used  in  orthopaedic  practice, 
would  prevent  or  minimise  the  severity  of  fractures 
to  feet  and  legs  that  might  occur  in  a  crash.  This 
apparatus  would  not  interfere  in  any  way  with  rudder 
bar  movements.  In  aerial  warfare,  and  particularly 
in  low  bombing  or  ground  "  strafing,"  there  is  a 
need  for  some  form  of  protective  armour  to  save  the 
pilot  from  bullet  wounds. 


The  Surgery  of  Aviation 

The  question  of  the  preparation  of  the  candidate 
by  surgical  procedures  to  fit  him  for  aviation  duties 
may  or  may  not  arise  in  peace  time,  but  during  war, 
when  man  power  may  be  a  difficult  problem  to  solve, 
it  is  certainly  part  of  the  Air  Force  surgeon's  duties 
to  carry  out  such  measures. 

Surgical  work  in  connection  with  aviation  in 
general  differs  but  little  from  that  found  in  military 
and  civil  life.  The  difference  is  mainly  one  of  degree 
in  that  one  is  mostly  called  upon  to  deal  with  the 
results  of  high  velocity  accidents  associated  with 
falls  at  varying  angles,  and  from  varying  heights. 
These  accidents  are  not  common  in  civil  life,  except 
in  such  occupations  as  those  of  mason,  steeplejack, 
window-cleaner,  shipbuilder,  etc.  Again,  in  the 
latter,  the  recipient  of  the  injuries  usually  falls  by 
himself,  unaccompanied  by  any  protective  material. 
On  the  other  hand,  the  aviator  falls  with  and  in  his 
aeroplane,  and  therefore  a  good  deal  of  the  shock  of 
impact  is  taken  up  by  the  woodwork  of  the  machine. 
This  may  explain  the  luck  that  ofttimes  befalls  the 
occupants  in  sometimes  the  most  appalling  crashes. 

Certain  surgical  conditions  are  found  in  aviation, 
the  result  of  thermal  causes.  Of  these  the  most 
severe  result  from  the  outbreak  of  fire,  occun'ing 
either  in  mid-air  or  on  crashing.  As  the  whole 
aeroplane  is  reduced  to  a  mere  framework  in  the 
course  of  a  few  minutes,  unless  the  aviator  is  lucky 



enough  to  be  thrown  out  or  extricate  himself  quickly, 
the  resulting  burns  are  often  severe  if  not  fatal. 
The  cold  at  high  altitudes  is  extreme,  and  aided 
by  the  rapid  transit  through  the  air,  is  apt  to  induce 
easily  frostbite.  This  may  occur  in  spite  of  all 
precautions.  Immersion  effects  as  in  seaplane  acci- 
dents may  give  rise  to  conditions  allied  to  trench 

The  projectile  wounds  received  in  war  flying  are 
much  the  same  as  those  found  in  ordinary  military 
surgery,  except  that  added  to  them  and  complicating 
them  may  be  other  injuries  should  the  aeroplane  be 
decontrolled  or  so  badly  damaged  that,  on  landing, 
a  crash  is  inevitable.  Surgical  work  in  connection 
with  aviation  may,  therefore,  be  conveniently 
arranged  in  three  departments,  as  follows  : — 

I.  The  Surgery  of  Preparation  for  Aviation. 
II.  The  Surgery  of  Aviation  in  General. 
III.  The  Surgery  of  War  Aviation. 

I.  In  the  Surgery  of  Preparation  for  Aviation  we 
have  to  deal  with  by  surgical  means — operative  or 
non-operative — the  various  defects,  the  cure  of  which 
will  render  fit  an  individual  for  flying  duties. 

{a)  Dental  treatment  is  of  special  importance 
before  commencing  flying.  It  is  a  well-known  fact 
that  the  cold  experienced  at  altitudes  combined  with 
the  rush  of  air  soon  lights  up  any  dental  sepsis. 
Therefore  the  aviator  should  commence  dentally 
clean.  All  cases  are  carefully  examined  for  pyorrhoea 
and  appropriate  treatment  carried  out. 

(6)  Throat  and  nose  conditions  are  of  equal 
importance  ;  septic  lacunar  tonsils  are  removed  by 
enucleation  ;  such  foci  are  apt  to  be  raised  into 
activity  by  flying.  At  altitudes  where  the  oxygen 
tension  is  lowered,  most  aviators  become  mouth- 
breathers.     A   dryness   occurs,    and   this   encourages 


the  growth  of  sepsis.  To  give  as  free  an  airway  as 
possible  any  adenoids  present  should  be  removed. 

For  the  same  reason  any  deflection  of  the  nasal 
septum  or  hypertrophy  of  the  turbinates  causing 
nasal  obstruction  should  be  corrected  by  performing 
submucous  resection  and  partial  turbinectomy.  There 
is  reason  to  believe  that  cases  of  enlarged  turbinates 
and  deflected  septa  are  more  liable  to  suffer  from 
headaches  on  reaching  high  altitudes.  A  colleague 
of  mine,  Capt.  Guthrie,  R.A.F.,  is  keeping  records 
of  such  cases,  before  and  after  operation,  with  regard 
to  this  question. 

It  is  essential  that  there  should  be  no  obstruction 
of  the  airway  to  the  middle  car  and  accessory  sinuses. 
Otherwise  with  the  sudden  changes  of  height  in 
flying  and  the  consequent  differences  in  atmospheric 
pressure,  there  are  liable  to  appear  such  symptoms 
as  earache,  headache,  and  vertigo. 

(c)  General  defects,  such  as  varicose  veins,  hernia, 
varicocele,  etc.,  that  would  form  an  inconvenience 
in  flying,  should  be  remedied  by  operative  measures. 

{d)  Ophthalmic  work  may  be  necessary  as  in 
correcting  visual  defects.  Much  can  also  be  done 
to  remedy  heterophoria  (concealed  squint)  by  ordering 
and  supervising  exercises  for  the  ocular  muscles  in 
such  cases. 

(e)  Orthopaedic  Surgery  plays  its  part  in  the 
correction  of  deformities  which  interfere  with  the 
movements  of  upper  or  lower  limbs,  and  would 
otherwise  prevent  an  individual  from  taking  up 
flying.  As  quite  a  number  nowadays  fly,  having  only 
one  lower  limb,  it  is  essential  that  the  surgeon  should 
advise  in  each  case.  He  should  also  see  that  the 
artificial  limb  is  light,  strong  and  reliable  in  every 
way.  Recently  the  author  passed  fit  for  flying  an 
officer  who  had  had  both  legs  amputated  below  the 
knee,  but  is  so  fitted  with  artificial  limbs  that  he  can 


easily  and  with  safety  perform  all  rudder  bar  move- 

II.  The  surgery  of  aviation  in  general  is  concerned 
mostly  with  the  results  of  high  velocity  accidents. 
These  consist  of  aeroplane  accidents  and  propeller 
accidents.  But  it  is  concerned  also  with  conditions 
resulting  from  thermal  causes,  such  as  frostbite 
produced  by  the  cold  of  high  altitude  flying  ;  and 
"  waterbite  "  or  a  condition  allied  to  trench  feet, 
and  produced  by  immersion  in  seaplane  accidents. 

Naturally  from  such  accidents  the  Air  Force  surgeon 
is  called  upon  to  deal  mostly  with  fractures,  disloca- 
tions, lacerated  wounds,  intracranial  injuries,  frost- 
bites, and  burns. 

Much  has  already  been  discussed  on  the  results 
of  aeroplane  accidents  in  the  preceding  chapter,  but 
it  is  well  to  keep  in  mind  the  following  factors  which 
determine  the  type  and  severity  of  the  injuries 

{a)  The  height  of  the  fall — naturally  the  greater 
this  is  the  more  severe  are  the  resulting  injuries, 

{h)  The  angle  of  the  fall,  upon  which  so  much 
depends.  In  vertical  dives  the  injuries  are  more 
severe  and  often  fatal.  In  falls  more  approaching 
the  gliding  angle  the  less  severe  are  the  injuries. 

(c)  Whether  with  engine  on  or  off.  With  the 
engine  on  the  injuries  are  much  more  severe,  and 
tliere  is  more  chance  of  the  outbreak  of  fire. 

{d)  Tlie  type  of  aeroplane.  In  propeller  machines 
or  "  pushers  "  (engine  behind)  the  injuries  received 
are  much  more  severe  and  more  hkely  to  be  fatal 
than  in  tractor  machines  (engine  in  front). 

[e)  The  position  of  the  pilot's  seat.  In  tractors 
the  nearer  this  is  to  the  engine  the  more  likely  is  he 
to  be  injured. 

{()  Whetlier  tlie  pilot  is  thrown  out  or  piinied  in 
the  wreckage.     If  thrown  out  tlie  injuries  are  usually 


of  the  upper  limbs  or  head.  If  pinned  in  the  wreckage 
the  lower  limbs  or  face  usually  suffer. 

(g)  If  the  pilot  falls  out  of  the  aeroplane,  gravity- 
alone  acts,  and  the  injuries  are  often  severe  or  fatal. 

(h)  Much  depends  on  how  the  injured  pilot  is 
extricated  from  the  wreckage.  A  simple  fracture 
may  be  converted  into  a  compound  one  by  trying 
to  extricate  the  pilot  from  the  wreckage  instead  of 
cutting  the  latter  away  from  him. 

First  aid  falls  to  the  lot  of  the  aerodrome  medical 
officer,  and  should  be  carried  out  as  described  in  the 
preceding  chapter. 

Surgical  shock  resulting  from  aeroplane  accidents 
is  often  severe  and  prolonged.  It  may  tax  all  the 
surgeon's  ingenuity  to  combat  this. 

Concussion  of  more  or  less  duration  occurs  in  most 
crashes.  During  this  period  a  great  deal  can  be 
done  in  accurately  diagnosing  fractures  or  reducing 
dislocations  before  much  swelling  arises. 

Of  the  various  fractures  all  varieties  are  found. 
Fractures  of  the  skull  are  usually  fatal.  Fractures 
of  the  upper  or  lower  jaw  or  nos(  are  very  common 
in  aeroplane  crashes.  This  is  due  to  the  fact  that 
the  impact  of  the  crash  causes  the  pilot's  face  to 
be  jerked  violently  forward  in  contact  with  the  cock- 
pit edge,  gun-mounting  or  instrument  board. 

Fractures  of  the  upper  limbs  are  not  common, 
and  are  mostly  found  in  those  who  have  been  thrown 
out  clear  of  the  wreckage. 

Fractures  of  the  lower  limbs  are  very  common. 
The  femur  often  gives  way  by  indirect  violence, 
the  tibia  usually  by  direct  violence.  At  the  Central 
R.  A. F.  hospital  we  have  had  excellent  anatomical  and 
functional  results  after  the  plating  of  simple  fractures 
carried  out  under  Lane's  technique.     (Fig.  12.) 

The  feet  and  ankles,  being  the  foremost  part  of 
the  pilot  to  take  the  shock  and  the  least  easily  drawn 



out  of  danger,  arc 
the  regions  in  wliich 
fractures  most  often 
occur.  The  author 
has  found  that  the 
bone  most  often  af- 
fected is  the  astra- 
gakis.  Fracture  of 
the  astragalus  is  so 
comparatively  rare 
in  civil  life  that  one 
might  say  this  form 
of  injury  is  peculiar 
to  aviation  acci- 
dents. So  much  so 
that  the  author  has 
ventured  to  name  it 
"  aviator's  astraga- 
lus." Within  the 
past  year  he  has  per- 
sonally seen  or  had 
under  his  care  thir- 
teen cases,  and  has 
notes  of  other  five 
cases,  making  eight- 
een in  all. 

As  the  fracture  is 
so  common  and  pe- 
culiar to  aviation,  it 
is  of  interest  to  go 
into  the  matter  in 
some  detail.  The 
comparative  rarity 
of  fractures  of  the 
astragalus  in  civil 
life  is  borne  out  by 
the      fact      that      at 

Fiu.  12. — I'latiiiK  of  right  femur.     Perfect 
anatomical  and  functional  result. 

general     hospitals    only    one 


or  two  cases  are  seen  in  the  course  of  a  year. 
There  is  also  scanty  reference  on  the  subject  in 
text-books  on  fractures.  Falls  from  heights  on 
to  the  feet  are  fairly  common  in  certain  civil 
occupations,  but  in  these  cases  the  os  calcis  is  the 
bone  that  usually  sustains  fracture.  In  the  latter 
the  patient  usually  falls  by  himself,  and  the  impact 
is  taken  on  the  heels.  The  force  is  exerted  in  a 
vertical  direction  through  the  lower  limbs.  If  the 
material  landed  on  is  fairly  solid  there  is  no  give  and 
the  force  is  distributed  through  the  nearest  bone,  the 
OS  calcis,  resulting  in  its  fracture.  | 

On  the  other  hand  the  aviator  usually  falls  within 
his  machine,  and  strikes  the  ground  at  an  angle.  The 
sole  of  the  foot  rests  on  the  rudder  bar,  but  with 
the  impact  the  latter  gets  pressed  into  the  instep 
just  in  front  of  the  heel.  Thus  the  force  is  exerted 
through  the  lower  limbs  at  an  angle,  and  the  astra- 
galus takes  most  of  it,  and  becomes  the  seat  of 

The  anterior  edge  of  the  tibia  acts  as  a  cutting 
wedge  on  the  astragalus.  There  is  also  a  certain 
amount  of  torsion  exerted  on  the  ankle  joint  due 
to  the  momentum  carrying  the  pilot  forward,  some- 
times out  of  the  machine.  Again,  the  machine 
may  not  strike  accurately  nose  on,  and  thus  one 
side  gets  more  crushing  effect  than  the  other. 
The  engine  may  be  driven  back  more  on  one  side 
than  the  other.  Often  one  side  alone  of  the  rudder 
bar  is  bent  backwards  and  only  one  foot  is  injured. 
Before  the  actual  fracture  occurs  the  foot  may  be  in 
a  position  of  acute  dorsi-flexion,  plantar-flexion  or 
may  be  inverted.  The  author  has  investigated  the 
majority  of  these  cases  with  regard  to  details  of  the 
crash,  examination  of  wreckage,  etc.,  and  in  order 
to  throw  some  light  on  the  mechanism  producing 
the  fracture.     In  many  cases  the  facts  are  obscured 


by  the  pilot  having  been  rendered  unconscious  at 
the  time  of  occurrence.      Bilateral  fracture  may  occur. 

Varieties  of  Fracture  of  Astragalus. 

I.  Compression  and  Crushing  Types. 

The  whole  astragalus  may  be  simply  compressed 
without  actual  fracture — a  skiagram  shows  the  bone 
somewhat  flattened  and  elongated  in  a  fore  and 
aft  direction.  This  fact  is  revealed  by  comparison 
with  a  skiagram  of  the  normal  foot.  There  is  no 
clinical  deformity,  but  there  is  tenderness  on  pressure. 
There  may  be  some  limitation  of  range  of  ankle 
joint  movements.  The  most  severe  types  show  a 
complete  crushing  of  the  body  of  astragalus,  with 
pain  on  pressure  and  limitation  of  movement. 

II.  Fractures  of  the  Neck  of  the  Astragalus. 
In  these  cases  the  anterior  articulating  edge  of  the 

tibia  acts  as  a  wedge,  cutting  or  crushing  the  neck 
of  the  astragalus.  Two  subtypes  are  found,  (a)  The 
neck  may  be  simply  fissured  with  no  displacement 
or  deformity.  This  is  revealed  by  skiagram,  and  a 
localised  area  tender  on  pressure,  {b)  The  neck 
may  be  split  through  and  the  head  and  neck  of  the 
bone  displaced  upwards  or  inwards.  In  some  cases 
impaction  is  found.     A  varus  deformity  may  result. 

III.  Fractures  of  the  Body  of  the  Astragalus. 

The  body  may  be  simply  fissured  without  displace- 
ment, or  it  may  be  split  and  rotated  in  the  mortice. 
On  the  other  hand  the  body  may  be  divided  in  two, 
and  the  following  displacements  occur,  (a)  The 
posterior  half  of  the  body  may  be  dislocated  backwards 
out  of  the  ankle  joint  and  lie  in  front  of  the  Tendo- 
Achilles.  Here  it  can  be  felt,  and  there  is  limitation 
of  ankle  joint  movements,  especially  dorsi-flexion. 
Danger  arises  from  the  displaced  fragment  pressing 


on  the  posterior  tibial  vessels  and  nerve,  {b)  The 
anterior  half  of  the  body  with  the  head  and  neck 
may  be  displaced  forwards  and  inwards,  causing  a 
marked  varus  deformity,  or  it  may  be  displaced 
outwards  causing  valgus. 

IV.  The  Posterior  Process  may  be  broken  off. 
Radiographic  comparison  must  be  made  with  the 
other  foot,  as  in  about  10  per  cent,  in  adult  life  the 
posterior  process  may  be  found  as  a  separate  bone> 
the  OS  trigonum. 

V.  Complicated  Fractures  of  the  Astragalus. 

All  varieties  may  be  found — ^the  fibula  may  be 
fractured  at  its  lower  end,  or  the  internal  malleolus 
of  the  tibia  carried  away.  The  lower  end  of  tibia 
may  be  separated  from  its  lateral  attachment  to 
the  lower  end  of  fibula,  and  the  fractured  astragalus 
may  be  found  separating  and  making  its  way  up- 
wards between  the  two  bones.  Owing  to  the  rupture 
of  ligaments  the  fractured  bone  may  be  dislocated 
either  from  the  ankle  joint  or  subastragaloid,  resulting 
in  all  types  of  dislocation  of  ankle  or  foot  as  described 
in  text-books.  The  fractured  astragalus  may  be 
shot  completely  out  of  the  ankle  joint,  through  the 
skin,  and  found  lying  by  itself.  (Plates  21  to  24 

Signs  and  Symptoms. 

Unless  one  is  on  the  spot  at  the  time  of  the  crash 
it  is  impossible  to  make  an  accurate  clinical 
diagnosis,  owing  to  the  very  rapid  onset  of 
swelling  and  oedema  of  foot  and  ankle.  Nov/  that 
attention  has  been  called  to  the  frequency  of  this 
fracture  in  flying  accidents,  it  is  hoped  the  ex- 
aminer will  keep  the  astragalus  more  in  mind.  Even 
marked  displacement  may  be  obscured  by  the  swel- 
ling.    If    the    injured    aviator    is   unconscious  more 

Plate  21a. — Fiactuie  throuL'h  neck  of  astratralus. 

Pr, \TK  21 H. — Fracture  of  a.straealus.     Comprossion  of  l)0(ly  and  fracture 
thiou'_'h  neck. 




I'r.ATE  22a.-    Frnetme  of  hoclv  of  astragalus. 




I'l.AiK  22i!.    -l-'rat  line  <it  liody  of  astiiicrjiln.s  with  dislocation  of  posterior 





Plate  2:3. — Fracture  of  body  of  astragalus,  with  dislocation  forward  and 
outward  of  posterior  frayniont. 

Platk  24. — Fracture  of  body  of  astrasfalus,  with  dislocation  forward  and 
inward  of  anterior  fiairment. 


accurate  clinical  diagnosis  can  be  made.  Reliance 
is  placed  chiefly  on  good  skiagrams,  and  the  author 
insists  that  the  normal  foot  should  also  be  skiagraphed. 
Stereoscopic  views  are  essential. 

A  study  of  the  uninjured  astragalus  reveals  great 
variations  in  length,  breadth,  size,  shape  of  articular 
surfaces,  and  angle  of  neck  to  body.  Seymour 
Sewell,  in  the  Journal  of  Anatomy  and  Physiology^ 
April,  1904,  gives  an  exhaustive  account  of  a  study 
of  over  1000  specimens  of  the  normal  astragalus. 
The  bone  is  an  extremely  important  one,  forming  as 
it  does  the  keystone  to  the  arch  of  the  foot.  It  is 
of  the  nature  of  a  block  and  pulley,  and  many  tendons 
pass  over  it.  It  takes  part  in  two  movements,  a 
hinge  movement  in  the  mortice  of  the  ankle  joint, 
and  a  rotary  movement  with  the  scaphoid. 


The  first-aid  treatment  consists  in  preventing  the 
injured  aviator  from  attempting  to  walk  or  stand. 
The  boot  has  to  be  quickly  but  gently  removed  ; 
and  may  have  to  be  cut  away.  If  the  injured  person 
is  unconscious  an  attempt  must  be  made  at  accurate 
diagnosis  and  perhaps  a  reduction  attempted  in 
some  eases.  Lint  soaked  in  strong  lead  lotion 
should  be  loosely  applied,  and  the  foot  placed 
gently  in  a  right  angled  tin  shoe  and  elevated. 
Skiagrams  should  be  taken  as  soon  as  possible,  as 
the  subsequent  treatment  will  depend  on  what  is 
revealed  by  them.  Morphine  is  usually  required 
to  allay  pain.  As  soon  as  possible  the  form  of  light 
massage,  as  advocated  by  the  late  Dr.  Lucas- 
Cham  pionierre,  should  be  carried  out. 

In  the  types  of  fracture  where  there  is  little  or  no 
displacement,  compression  types,  fissured  fractures 
of  neck  or  body,  or  fractures  of  posterior  process, 
tlie  light   massage  should   be  followed  by  strapping 


of  the  foot  and  ankle  as  carried  out  by  the  late  Dr. 
^^^larton  Hood.  The  foot  is  placed  in  a  tin  shoe 
with  quadrant,  and  the  whole  elevated.  The  mas- 
sage, which  becomes  firmer  daily,  is  applied  over 
the  strapping,  and  as  the  latter  becomes  loose,  it  is 
not  removed  but  fresh  strapping  applied  over  it. 
In  a  week's  time  the  tin  sl\oe  is  taken  off  during  the 
day,  but  must  be  reapplied  at  night,  and  passive  and 
active  movements  at  the  ankle  are  encouraged.  The 
patient  is  allowed  up  on  crutches  at  the  end  of  a 
fortnight,  but  should  not  be  allowed  to  bear  weight 
on  the  injured  foot  for  at  least  sixty  days  since  the 
occurrence  of  the  fracture.  These  cases  should 
all  do  well,  and  all  disability  forgotten  in  six  to  nine 

^Vhere  there  is  marked  displacement  and  deformity 
resulting,  open  operation  should  be  performed.  Accur- 
ate anatomical  reposition  is  impossible  without  open 
operation.  The  surgeon  may  have  to  choose  one  of 
three  operations,  open  reposition  of  the  fragments, 
partial  astragalectomy,  or  total  astragalectomy. 
The  choice  will  depend  on  the  type  of  case,  and 
whether  it  is  a  recent  fracture  or  one  of  old  standing. 

The  route  for  exposing  the  fractured  bone  will 
depend  on  the  nature  of  the  displacement,  and  the 
resulting  deformity.  The  external  incision  over  the 
lower  end  of  the  fibula,  curving  forward  a  little  at 
its  lower  end,  gives  a  good  exposure  either  for  reposi- 
tion or  astragalectomy.  The  internal  incision  is 
of  value  in  some  cases.  In  very  complicated  cases  of 
old  standing  both  routes  may  have  to  be  adopted. 
If  the  posterior  half  of  the  body  is  dislocated  back- 
wards an  incision  is  made  over  it,  parallel  to  the  Tendo- 
Achilles.  (Fig.  13.)  The  technique  is  carried  out  as 
advocated  by  Lane,  except  that  sutures  are  employed 
instead  of  skin  clips.  Immediate  operation  may  have 
to  be  done  to  relieve  the  pressure  of  a  fragment  on  the 



vessels  and  nerves  around  the  ankle  joint,  but  it  is  better 
if  possible  to  postpone  the  operation  for  at  least  a 
Meek.  This  is  done  to  allow  the  swelling  to  go  down  and 
also  that  blebs  and  exeoriations  may  be  treated. 
Careful  attention  must  be  given  to  the  preparation 
of  the  foot  and  leg  for  operation.  Iodine  is  applied 
eaeh  day,  the  leg  is  shaved,  and  speeial  attention  is 

Fio.  13. — Showing  incision  parallel  to  Tendo-Acliilles 
for  removal  of  posterior  fragment. 

paid  to  the  intervals  between  the  toes.  No  tourniquet 
is  used  at  the  operation,  and  no  vessels  are  ligated  if 

A  free  exposure  is  made  of  the  fractured  bone  by 
one  of  the  routes  described  above.  There  should 
be  little  haemorrhage  and  no  important  structures 
are  divided.  An  assistant  can  give  great  help  by 
manipulating  the  foot  as  required.     Lane's  levers  are 


useful  in  manipulating  fragments.  In  attempting 
reposition  great  difficulty  may  be  encountered, 
especially  if  it  is  an  old  standing  case.  The  displaced 
portion  is  manipulated  into  position,  and  an  attempt 
made  at  impaction.  This  operation  is  only  of  value 
in  recent  cases. 

In  partial  astragalectomy  it  may  be  that  the 
posterior  half  of  the  bone  has  to  be  removed,  or  it 
may  be  the  head  and  neck.  The  latter  if  displaced 
often  forms  a  bony  block  to  dorsi-flexion,  and  often 
produces  a  varus  deformity.  Partial  astragalectomy 
is  performed  to  relieve  these  conditions.  After  the 
operation  the  foot  and  leg  are  put  in  plaster  at  a  right 
angle.  The  plaster  is  removed  in  ten  to  fourteen  days, 
the  stitches  are  removed,  and  massage,  passive  and 
active  movements,  commenced.  The  foot  is  retained 
at  night  in  a  tin  shoe  with  quadrant  and  the  foot 
gi-adually  screwed  up  each  day  beyond  the  right  angle. 
The  patient  is  allowed  up  on  crutches  three  weeks 
after  the  operation,  but  no  weight  is  to  be  borne  on 
the  injured  foot  for  at  least  sixty  days. 

In  some  cases,  especially  where  the  whole  bone 
is  involved,  or  if  there  s  much  rotation  of  the  frag- 
ments, or  of  old  standing,  it  is  better  to  perform 
total  astragalectomy.  If  the  tibial  mortice  is  not 
injured  much,  then  a  very  good  result  is  to  be  ex- 
pected, both  as  regards  range  of  movement  and 
weight  bearing  capacity.  The  same  after-treatment 
is  employed  as  for  partial  astragalectomy.     (Fig.  14.) 

It  may  be  necessary  to  aid  the  position  of  the  foot 
when  walking  is  commenced  by  ordering  a  surgical 
boot  with  light  double  steel  supports  to  below  knee 
and  with  valgus  and  varus  T  straps.  An  upraising 
toe-spring  is  added  if  necessary.  A  valgus  or 
varus  wedge  is  applied  to  the  boot  as  required. 
Fracture  of  the  astragalus  is  a  serious  crippling 
injury,  and  history  and  past  experiences  show  that 


the  results  in  many  cases  are  unsatisfactory.     Each 
case  must  be  treated  on  its  merits. 

The  following  is  a  short  account  of  the  eases  of 
fracture  of  the  astragalus  as  the  result  of  flying  acci- 
dents either  under  the  care  of,  or  investigated  by  the 
author  : — 

Case  1. — Lt.  McL.,  age  22,  tractor  machine,  crashed 
6/1/18,  belt  held,  not  throAni  out,  engine  crushed  into  cock- 

iic;.  14. — Skiagram  after  total  astragalectomy. 


pit  injuring  right  foot.  Fissured  fracture  of  neck  of  astra- 
galus. Pain,  sAvelling,  could  not  bear  weight  or  dorsiflex 
beyond  right  angle.  Tin  shoe  with  quadrant,  massage,  passive 
and  active  movements.  Good  anatomical  and  functional 
result.     Walking  well  in  three  months  from  injury. 

Case  2. — Lt.  G.,  age  22,  tractor  machine,  crashed  16/2/18, 
pinned  in  wreckage,  miconscious,  bilateral  injury  of  feet. 
Fracture  of  neck  of  right  astragalus,  compression  of  left 
astragalus  with  fracture  of  posterior  process.  Considerable 
swelling,  limitation  of  ankle  movements,  valgus  deformity. 


Treatment  as  in  Cas3  1,  valgus  pads  and  straps  added,  also 
given  radiant  heat.  In  three  months  valgus  overcome,  walks 
well,  but  feet  easily  tired. 

Case  3. — Lt.  B.,  age  24,  shot  down  26/12/17.  Unconscious 
14  days,  severe  multiple  injuries,  including  fracture  of  left 
astragalus.  Marked  vanis  deformity  with  little  movement 
at  ankle.  Fracture  through  body  of  astragalus  with  anterior 
half,  head  and  neck  displaced  outwards  and  lying  in  front  of 
external  malleolus.  Partial  astragalectomy,  19/3/18.  Varus 
considerably  reduced  and  fair  movement  at  ankle,  wears  tin 
shoe  at  night  and  short  varus  walking  apparatus  during  day. 

Case  4.— Lt.  B..  age  22,  tractor  machine,  crashed  29/2/17. 
Unconscious,  fracture  of  upper  jaw  and  left  astragalus. 
Fracture  through  body  just  posterior  to  neck.  Latter  dis- 
placed outwards,  causing  varus  deformity  with  inability  to 
dorsiflex,  bony  block.  Admitted  3/3/18.  Forcible  manipula- 
tion, and  plaster,  later  tin  shoe  and  varus  boot  and  walking 
apparatus.     To  return  for  partial  astragalectomy. 

Case  a.- — P.F.O.  McD.,  age  20,  tractor  machine,  crashed 
7/4/18.  thrown  out,  great  swelling  around  ankle.  Fracture 
through  body  of  left  astragalus  with  dislocation  Ijackwards 
of  posterior  half.  Foot  in  equinus,  cannot  dorsiflex. 
Posterior  fragment  removed  25/5/18,  good  anatomical  result, 
fair  range  at  ankle,  walks  with  a  limp  four  months  after 

Case  6. — Lt.  R.,  age  34,  observer,  tractor  machine,  thrown 
out,  fissured  fracture  of  neck  of  right  astragalus,  tip  of  internal 
malleolus  fractured,  no  deformity  but  stiffness  of  ankle. 
Tin  shoe  with  quadrant,  massage  and  movements,  good  result 
in  two  months  from  injury. 

Case  7. — Lt.  C,  age  25,  tractor  machine,  crashed  5/6/18, 
partial  nose-dive,  nidder  bar  twisted  back  injuring  right  foot, 
fracture  through  body  of  astragalus,  rotation  of  anterior 
fragment  with  displacement  foi'ward  causing  talipes  equino- 
varus,  cannot  dorsiflex  to  right  angle.  Total  astragalectomy 
10/9/18,  not  allowed  to  walk  for  60  days,  good  anatomical 
and  functional  result.     (Plates  25  and  26.) 

Case  8.^ — Lt.  M.,  aged  — -,  decontrolled  and  crashed  12/8/17. 
Piimed  in  wreckage,  unconscious,  fracture  through  neck  of 
right  astragalus,  also  tip  of  external  malleolus.  Tavo  manipu- 
lations, massage,  electrical  treatment  and  movements,  good 
functional  result  but  requires  a  valgus  wedge  in  right  boot. 

Case  9. — Lt.  S.,  age  25,  tractor  machine,  crashed  26/1/18. 
Unconscious,  fracture  of  right  astragalus  through  body  with 



dislocation  of  fragment  forwards  and  outwards  in  front  of 
external  malleolus.  Foot  in  varus  -with  limited  movement 
at  ankle,  partial  astragalectomy  on  4/4/18.  Four  months  later 
good  anatomical  result,  fair  range  at  ankle  but  walks  with 

Case  10. — Lt.  M,,  age  27,  observer,  tractor  machine, 
crashed  6/12/16.  Unconscious,  pilot  killed,  pinned  in  wreck- 
age, fracture  lower  third  left  fibula,  dislocation  inferior 
tibio-fibular  joint,  fracture  of  upper  surface  of  body  of 
astragalus.  Proposed  operation :  exposure  of  ankle  joint, 
freshen  inferior  tibio-fibular  joint  to  obtain  bony  union  and 
aid  this  by  inserting  a  bone  peg  through  lower  ends  of  tibia 
and  fibula,  total  astragalectomy  depending  on  condition  of 
that  bone. 

Case  11.— Mr.  K.,  age  — ,  pusher  machine,  crashed  23/2/14. 
Not  thrown  out,  unconscious,  fracture  of  right  femur, 
fracture  of  right  astragalus,  displacement  of  anterior  portion 
outwards  in  front  of  external  malleolus,  deformity  is  valgus. 
Now  wears  a  valgus  walking  apparatus,  can  walk  three 
miles,  good  range  at  ankle. 

Case  12. — Capt.  B.  I,,  age  24.  shot  doAvii,  multiple  injuries, 
unconscious,  fracture  of  left  astragalus,  crushing  of  body, 
deformity  varus,  excision  of  posterior  half  of  astragalus. 
\Voars  a  varus  wedge,  and  T  strap,  movement  at  ankle,  to 
right  angle  only,  bony  block. 

Case  13.— Maj.  A.,  age  — ,  crashed,  fissured  fracture  of 
neck  of  left  astragalus.  Good  anatomical  and  functional 

Mr.  F.  F.  Burghard  has  kindly  furnished  the  author 
with  the  notes  of  this  case,  No.  14,  which  was  under 
Ills  earf. 

Case  14.— Lt.  T.,  age  19,  crashed  28/5/16,  fracture  of  neck 
of  right  astragalus,  head  and  neck  being  displaced  forwards, 
u] (Wards  and  inwards,  fracture  of  internal  malleolus  and  varus 
deformity.  0})cration  on  fifth  day,  inner  route,  open  reposition 
of  head  and  neck  of  astragalus,  internal  malleolus  plated. 
X-llay  shows  perfect  position,  good  anatomical  and  func- 
tional result.     Killed  in  France  early  1917. 

The  author  is  indebted  to  Mr.  Paul  Bernard  Roth 
for  notes  of  cases  15   and  16,   and   also   for   asking 
liiin  to  see  Case  16. 


Case  15.- — Lt.  G.,  age  25,  crashed  on  4/2/15,  sustained 
fracture  of  right  ulna,  left  astragalus  and  internal  malleolus, 
fracture  was  through  the  body  of  the  astragalus  and  the  pos- 
terior fragment  was  dislocated  backwards  and  lying  in  front  of 
Tendo- Achilles.  Posterior  fragment  removed  by  Mr.  English 
ten  days  later ;  seen  by  Mr.  Roth  on  the  15/7/15,  deformity 
talipes  equinus  due  to  bony  block,  and  could  only  walk  300 
yards.  Remainder  of  astragalus  removed  by  Mr.  Roth  ;  good 
result.  In  1917  was  doing  full  duty,  playing  tennis,  etc., 
killed  later. 

Case  16. — Air-Mech.  F.,  age  20,  observer,  jumped  from 
an  aeroplane  just  before  the  crash.  Compression  fracture  of 
body  of  left  astragalus,  with  fissures  radiating  from  inferior 
aspect,  developed  a  neurosis,  functional  equinus,  atrophy  of 
nmscles  of  leg  and  hyperalgesia  ov?r  ankle,  subcutaneous 
lengthening  of   Tendo-Achilles   by   Mr.   Roth ;  good   result. 

The  author  has  to  thank  Col.  Openshaw  for  allow- 
ing him  to  include  this  case,  No.  17,  in  the  present 

Case   17. — Lt.  ,   crashed   summer,    1918,   bilateral 

fracture  of  astragalus,  immediate  operation  by  Col.  Open- 
shaw, who  removed  a  large  dislocated  fragment  pressing  on 
posterior  tibial  nerve  and  vessels.  The  other  foot  did  not 
require  operation. 

Case  18. — Name  unknown,  reported  to  me  by  Capt. 
Denny,  U.S.M.R.,  nose  dive,  crash,  killed  outright.  Among 
other  injuries  one  astragalus  was  fractured  and  shot  clean 
through  the  skin  and  free  from  the  body. 

The  only  other  fracture  of  peculiar  interest  in  the 
surgery  of  aviation  is  telescoping  fracture  of  the  spine 
without  involvement  of  the  spinal  cord.  The  author 
has  now  seen  five  such  cases.  They  result  from  severe 
aeroplane  crashes.  There  may  be  other  compli- 
cating injuries  and  the  spinal  condition  at  first  may 
be  overlooked.  The  pain  is  severe,  and  lasts  for 
some  time.  Deformity  of  the  spine  may  or  may  not 
be  present.  Surgical  shock  is  extreme.  The  severe 
and  localised  pain  should  lead  one  to  suspect  this 
type   of   injury.     A   good   skiagram   will   reveal   the 



condition.  The  lower  thoracic  spine  is  the  part  usually 
involved.  The  centrum  of  one  vertebra  is  found 
telescoped  into  the  one  below  it.  If  this  occurs 
evenly  there  is  little  resulting  deformity.  If  the 
telescoping  is  uneven,  and  one  half  of  the  centrum 
is  driven  down  laterally  more  than  tlie  otlier  tlien  a 

Fid.   J.J. — .Showing  broken  propeller  blades  which  severely  injured  a 
mechanic  through  a  "'  backfire." 

scoliosis  is  produced.  In  other  cases  the  anterior 
half  of  the  centrum  gets  driven  down  more  and  a 
kypliosis  residts. 

Pain  and  surgical  shock  have  to  be  combated  at 
first.  The  patient  nuist  be  nursed  in  a  special 
s])iiial  bed.  At  the  end  of  three  niontlis  lie  is  allowed 
up,  but  should  be  fitted  with  a  moulded  leather  or 
pexulloid  spinal  support  with  arm  crutches.      Skia- 


grams  should  be  taken  from  time  to  time  to  watch 
the  progress  of  the  case.  If  the  kyphosis  increases  it 
may  be  necessary  to  perform  Albee's  operation. 
Neurasthenia  is  apt  to  follow  this  type  of  injvuy. 

Propeller  accidents  often  result  in  severe  injuries 
mostly  to  the  upper  limbs  or  head.  In  swinging  the 
propeller  to  start  the  engine  a  backfire  may  occur, 
and  the  propeller  suddenly  revolves  in  the  opposite 
direction.  Contusions,  lacerated  wounds,  or  fractures 
may  occur.     (Fig.  15.) 

Surgical  Conditions  due  to  Thermal  Causes. 
I.  Burns. 

The  outbreak  of  fire  may  occur  in  mid-air,  and  is 
then  usually  the  result  of  an  aerial  duel,  or  it  may 
occur  on  landing  in  certain  aeroplane  crashes. 
There  is  less  danger  of  fire  in  these  crashes  if  the 
engine  is  switched  off  beforehand.  In  a  two-seater 
machine  if  an  observer  be  carried,  the  latter,  by 
means  of  the  Pyrene  extinguisher,  can  do  much  to 
quell  an  outbreak  of  fire  in  mid-air.  The  pilot,  by 
side  slipping  the  aeroplane  the  whole  way  to  earth, 
may  prevent  the  fire  damaging  the  vital  parts  of  the 
machine,  and  also  save  his  observer's  life  as  well  as 
his  own.  This  manoeuvre  throws  the  flames  outboard 
in  the  direction  opposite  to  the  sideslip.  A  very 
sudden  and  steep  nose  dive  might  quell  the  outbreak, 
but  on  the  other  hand  the  flames  may  be  carried  back 
and  damage  such  vital  parts  as  the  rudder  and 
elevator.  The  parachute  is  the  best  means  of  escape, 
and  these  should  be  provided  in  every  aeroplane. 
Those  who  have  experienced  fire  in  the  air  or  have 
witnessed  such  sights,  the  most  distressing  in  aviation, 
will  readily  endorse  this  view.  On  the  event  of  fire 
occurring  in  mid-air,  safety  belts  should  be  at  once 
released.     If   fire    breaks  out  on  crashing,  the  occu- 


pants  may  escape  if  thrown  clear  of  the  wreckage. 
If  in  the  machine  they  are  not  hkely  to  escape. 

Asbestos  blankets  are  extremely  useful  as  a  means 
of  first  aid.  By  wrapping  them  round  the  injured 
persons  the  spread  of  fire  on  clothing,  etc.,  can  be 
limited.  If  asbestos  blankets  are  not  available, 
leather  flying  coats  can  be  used.  Picric  acid  dressings 
are  applied,  or  "  carron  "  oil  if  it  is  available.  Mor- 
phine is  injected,  and  chloroform  should  be  admin- 
istered if  there  is  nmch  pain.  The  chief  difficulty  is 
in  combating  shock  and  chest  complications.  AVlien 
the  shock  passes  off  the  original  dressings  are  changed 
under  an  anaesthetic,  and  are  replaced  by  the  appli- 
cation of  ambrine,  once  the  burns  are  gently  but 
thoroughly  cleansed. 

Red  lotion  and  scarlet  red  ointment  are  useful  in 
the  later  stages. 

Burns  of  the  first,  second,  and  third  degrees  are 
the  usual  ones  encountered.  The  author  has  seen 
one  case  of  burns  of  lower  limbs  and  abdomen  caused 
by  petrol.  The  rapid  transit  tlirough  the  air  increased 
its  action  as  a  vesicant. 

In  the  after  treatment  in  these  cases  it  may  be 
found  very  difficult  to  prevent  contraction.  It  may 
be  impossible  to  apply  extension.  Much  can  be 
done  by  gentle  passive  movements  during  the  healing 
stage.  And  again  postin-al  methods  may  be  of  use. 
Once  the  biu*n  has  healed,  the  resulting  cicatrix  goes  on 
contracting  for  quite  a  long  time,  but  it  must  be 
remembered  that  the  young  fibrous  tissue  composing 
it  is  distensile  as  well  as  contractile.  Advantage 
should  be  taken  of  this  fact  to  carry  on  with  oil 
massage,  kneading,  and  gentle  stretching  as  soon  as 
the  burns  liave  healed.  Skin  grafting  and  plastic 
operations  niay  have  to  be  carried  out  to  complete 
the  treatment. 


II.  Aerial  Frostbite. 

In  school  flying,  except  in  some  cases  attempting 
height  tests  in  winter,  frostbite  conditions  are  rarely 
seen.  But  in  a  bombing  squadron,  where  the  forma- 
tion, in  order  to  reach  its  objective,  has  to  keep  at 
high  altitudes  perhaps  for  some  hours,  to  avoid 
detection  or  the  attentions  of  "  Archie,"  the  cold 
experienced  is  extreme,  and  from  time  to  time  cases 
of  frostbite  occur.  At  such  squadrons  the  pilots 
are  provided  with  warm  and  suitable  clothing,  and 
precautions  are  taken  by  smearing  the  exposed  parts 
with  some  greasy  preparation.  Many  efforts  have 
been  made  to  provide  electrically-heated  garments, 
but  some  of  these  have  not  proved  a  very  great 
success.  The  author  was  well  satisfied  with  one 
type  of  suit  which  he  tried.  Frostbite  is  a  form  of 
gangrene  brought  on  by  exposure  to  cold,  and  the 
parts  usually  affected  are  the  face,  fingers,  and  toes. 
The  condition  is  more  likely  to  supervene  where  the 
circulation  is  enfeebled  or  where  any  constriction 
is  present  interfering  with  the  circulation.  The  tissues 
do  not  die  when  frozen,  but  in  the  subsequent  thawing, 
in  which  intense  capillary  congestion  sets  in.  The 
affected  parts  become  dead  white,  accompanied  by 
loss  of  sensation,  due  to  stasis  of  the  circulation. 
This  is  followed  by  a  reactionary  period  when  the 
full  extent  of  the  mischief  becomes  revealed.  In 
sHght  cases  an  erythema  follows  accompanied  by 
slight  swelling,  and  hyperaesthesia,  and  later  followed 
by  a  period  of  desquamation. 

In  other  cases  the  swelling  and  oedema  become  very 
marked  and  bullae  form.  Certain  areas  may  die  and 
form  necrotic  patches.  In  more  severe  cases  a  finger 
tip,  a  toe,  or  tip  of  the  nose  may  be  lost  through  death 
of  the  parts.  The  reaction  period  is  usually  accom- 
panied by  great  pain.  The  oedema  takes  some  time  to 
subside  and  convalescence  is  often  protracted.     As  the 


swelling  subsides,  the  tissues  undergo  repair  and 
desquamation  oeeurs.  For  some  time  afterwards  a 
})eculiar  sensitiveness  to  eold  persists  in  the  affected 
j)arts.  The  author  has  only  seen  a  few  eases  of  aerial 
frostbite,  mostly  slight  and  affeeting  the  fingers  and 
nose,  but  was  impressed  by  the  slow  recovery  in 
these  cases. 

Surgeon-Lieutenant  A.  G.  Holman,  R.N.,  who  has 
had  a  long  experience  with  a  squadron  which  had 
to  carry  out  high  altitude  flying  in  very  cold  weather, 
has  very  kindly  furnished  me  with  the  following 
notes  of  four  cases  of  aerial  frostbite,  and  appended 
are  his  views  on  prophylaxis  and  treatment  of  such 

"  Case  1.— Flight  Sub-Lieut.  K..  aet  22.  Returned  from 
Ijombing  raid  after  two  hours'  flying  at  an  average  altitude 
of  10. 000  feet.  Temperature  on  the  ground  13°  F.  He  did 
not  coiuplain  of  any  pain  or  discomfort  at  the  time,  and  his 
condition  was  only  discovered  during  a  routine  examination 
of  all  pilots  as  they  landed.  He  was  found  to  have  some 
brawny  swelling  of  the  cheeks.  Treatment  consisted  only 
of  keepin<^  the  patient  away  from  excessive  warmth  until 
the  face  had  thawed,  and  application  of  a  mixture  of  equal 
parts  of  lanoline  and  vaseline. 

"  There  was  very  little  swelling  next  day  and  no  vesica- 
tion, and  forty-eight  hours  afterwards,  except  for  a  very  slight 
desquamation  of  the  <heeks,  there  was  no  further  trouble. 

"  Case  2. — Flight  Sidj-Lieut.  M.,  aet  27.  Returned  from 
bombijig  raid  of  about  two  and  a  half  hours'  duration. 
Face  \'eiy  swollen  though  jiot  particularly  painful.  Next 
day  the  face  was  enormously  swollen,  the  cheeks  being  almost 
in  line  Avith  the  tips  of  the  shoalders,  and  in  addition  there 
was  much  redness  and  some  vesication  of  the  skin  ))elow  the 
light  angle  of  the  mouth.  This  latter  developed  into  a  fairly 
siiperli<'ial  necrotic  j^atcli  about  the  size  of  a  crown  piece. 

"  Tr<;itmcnt  consisted  of  kee[)ing  the  face  warm  by  wool 
and  bandage,  and  dusting  powder  to  the  necrotic  patch. 
Later  a  /inc  oxide  ointment  dressing  was  applied  to  this 
Iatt<r.  The  swellijig  gradually  decreased,  and  the  slough 
turned    black  and   s<])arated.    leavino-  ;i  h<'alth>'  base  about 


the  fifteenth  day.  The  face  was  very  painful  for  some  weeks 
after  this  whenever  exposed  to  the  cold. 

"  Case  3.^ — Flight  Sub-Lieut.  D.,  aet  32  (a  mouth-breather). 
Returned  from  the  same  flight  with  marked  swelling  of  the 
cheeks  and  intense  inflammation  of  the  lower  lip.  Next 
day  there  was  some  vesication  of  the  lower  lip  and  later 
extensive  superficial  necrosis  of  the  lip.  The  swelling  sub- 
sided -without  further  trouble  in  a  few  days.  The  necrosis 
of  the  lip  was  treated  with  zinc  oxide  ointment  dressing,  and 
sloughs  separated  about  the  fifteenth  to  the  twentieth  day, 
leaving  rather  a  painful  inflamed  surface,  which  later  healed 
well  and  gave  no  further  trouble. 

"  Case  4. — Air-Mechanic  Gunlayer  F.,  aet  21,  whilst 
fighting  at  10,000  feet,  was  forced  to  remove  his  gloves  to 
clear  a  jambed  Lewis  gun.  In  doing  this  he  lost  both  gloves, 
and  had  to  continue  fighting  for  three-quarters  of  an  hour 
without  gloves.  The  temperature  on  the  ground  at  this 
time  was  5^*  F. 

"  He  was  discovered  a  few  minutes  after  landing,  warming 
his  hands  before  a  fire.  The  hands  were  intensely  swollen, 
and  brawny  though  there  was  hardly  any  pain.  They  were 
immediately  placed  in  snow,  and  very  slowly  thawed  out. 
There  was  then  fomid  to  be  some  vesication  of  the  fingers. 
The  vesicles  were  incised,  and  the  whole  hands  immersed  in 
dilute  picric  acid  solution,  and  finally  covered  with  lint 
wrung  out  in  the  same  solution. 

"  Next  day  there  was  vesication  of  the  whole  of  the  dorsal 
surface  of  both  hands.  These  vesicles  were  incised  and 
treated  with  the  dilute  picric  acid  dressing.  The  nails  were 
very  discoloured,  and  there  was  complete  anaesthesia  to 
touch  from  the  wrists  downwards. 

"  Picric  acid  dressings  were  continued  for  ten  days,  when 
the  bases  of  the  vesicles  had  healed,  and  a  dusting  powder 
and  gauze  dressing  then  substituted.  The  anaesthesia 
gradually  disappeared,  remaining  longest  at  the  tips  of  the 
fingers.  There  was  extensive  superficial  necrosis,  which 
separated,  lea\ing  perfectly  clean  underlying  surfaces  after 
some  twenty-three  days.  The  patient  complained  of  stiff- 
ness of  his  fingers  for  several  weeks,  but  was  able  to  return 
to  ground  duties  after  five  weeks'  treatment  from  the  time 
of  his  first  being  frostbitten.  Ultimately  he  had  a  perfectly 
good  pair  of  hands  Avith  very  little  scar  tissue. 

"  The  above  were  the  only  cases  of  aerial  frostbites 


that  came  under  my  notice,  although  I  have  seen  a 
great  deal  of  flying  in  very  cold  weather.  Several 
pilots  of  my  early  acquaintance  used  to  smear  a 
little  vaseline  on  the  exposed  portions  of  their  faces, 
and  this  vmdoubtedly  did  much  to  prevent  frostbite, 
though  Cases  1  and  3  both  had  vaseline  on  their  faces. 
During  cold  weather  I  made  a  point  of  anointing 
every  pilot's  face  with  equal  parts  of  lanoline  and 
vaseline  mixed,  and  not  one  of  those  so  treated  ever 
developed  frostbite,  ^^^l ether  or  no  the  lanoline  be- 
comes to  a  certain  extent  absorbed  by  the  skin,  and  thus 
makes  a  more  protective  covering,  I  cannot  say,  but 
the  mixture  seems  much  more  effective  than  vaseline 
alone.  There  is  one  more  point  in  the  prophylaxis  of 
aerial  frostbite  that  appears  to  me  important,  and 
that  is  the  kind  of  fur  used  in  the  manufacture  of 
face  masks,  goggles,  etc.  North  American  trappers 
have  found  that  the  only  fur  that  will  not  become 
frosted  by  the  breath  in  the  coldest  weather  is 
wolverine,  and  this  is  the  fur  that  they  always 
select  for  their  own  headgear  and  face  protection. 
Case  3  above  was  a  mouth-breather,  and  the  chin 
band  of  his  helmet  was  quite  frozen  stiff  with  his 
breath  when  he  landed,  and  frozen  to  his  lower  lip. 
I  used  to  make  a  point  of  examining  every  pilot 
on  his  return  from  a  flight  in  cold  weather,  immedi- 
ately he  got  out  of  his  machine,  to  ensure  that  no  one 
who  should  liappcn  to  be  frostbitten  should  go  into 
the  hot  atmosphere  of  the  mess  or  cabin  before  being 
previously  slowly  thawed  out.  One  point  that  par- 
ticularly struck  me  Wiis  the  almost  entire  absence 
of  pain,  particularly  with  more  severe  cases.  And 
this  alone  in  my  opinion  calls  for  the  routine 
examination  described  above,  as  the  pilot  is  generally 
completely  unaware  of  liis  condition." 


III.  Waterbite. 

This  is  the  name  appHed  to  conditions  aUied  to 
trench  feet  and  due  to  the  effects  of  prolonged  exposure 
to  cold  water.  It  is  found  in  seaplane  work,  and 
therefore  it  is  essential  that  all  seaplane  pilots 
going  on  patrol  should  be  adequately  clothed  and 
protected.  Lanoline  ointment  should  be  applied 
to  the  lower  limbs,  long  woollen  stockings  worn, 
and  over  the  ordinary  trousers  there  should  be  sea- 
boots  extending  to  the  hips.  The  lower  and  upper 
limbs  are  the  parts  usually  affected.  At  first  they 
become  benumbed  and  white  in  colour.  There  is 
no  complaint  of  pain.  There  is  usually  some  swelling 
of  the  parts,  then  large  bullae  form,  and  the  colour 
becomes  mottled.  Pain  sets  in  about  the  third  day, 
is  usually  intense  and  may  last  for  weeks.  Painful 
cramps  in  the  muscles  are  a  distressing  feature. 
With  the  local  reaction,  soon  a  line  of  demarcation 
forms,  and  depending  on  the  treatment,  the  clinical 
picture  is  one  of  moist  or  dry  gangrene.  Loss  of 
fingers  or  toes  may  occur,  and  owing  to  the  devitalised 
condition  of  the  tissues,  the  wounds  are  slow  to  heal. 
The  affected  parts  should  be  bathed  with  spirit, 
dried,  powdered,  wrapped  loosely  in  cotton  wool  and 
elevated.  Gentle  massage  with  oil  may  be  tried 
in  the  reaction  stage.  Opium  is  given  to  relieve  the 
pain,  and  exerts  a  local  influence  in  that  it  causes 
dilatation  of  the  peripheral  vessels.  Preventative 
orthopaedic  measures  should  be  carried  out  during 
the  treatment. 

The  following  is  an  account  of  a  case  of  "  water- 
bite,"  at  present  under  the  author's  care  : — 

Flight  Sub. -Lieut.  M.,  age  24,  observer,  with  Lt.  S.,  pilot, 
in  a  seaplane  in  foggy  weather  were  forced  to  land,  owing  to 
engine  failure  ;  and  in  doing  so  the  tail  float  was  broken. 
Slowly  the  whole  machine  sank,  tail  first,  and  turned  right 
over,  so  that  pilot  and  observer  found  themselves  seated  on 


Avhat  had  been  the  under  surfaces  of  the  main  floats.  For- 
tunately the  submerged  seaplane  broke  adrift  from  the  floats 
and  sank.  (Fig.  16.)  M.  and  S.,  each  on  a  float,  were  in  this 
position  for  three  nights  and  four  days,  without  food  or  drink, 
and  exposed  to  the  action  of  cold  water  for  most  of  that 
time.  M.  was  in  ordhiary  uniform,  slacks  and  ordinary  boots, 
while  S.  had  on  leather  field  boots.  The  former's  feet  and 
legs  were  benumbed  the  whole  time,  and  his  hands  became 
swollen.     Tn    an    exhausted    condition    thev    were    rescued 

J?"iG.  W. — Showing  a  sinking  seaplane  with  under  surface  of  main  floats 
now  uppermost. 

near  the  end  of  the  fourth  day.  S.  did  not  suffer  so  badly, 
but  was  uiuible  to  walk  for  many  weeks.  M.  suffered  severely 
from  pain  in  the  feet  and  cramps  in  the  legs  for  over  three 
weeks.  The  parts  became  mottled,  large  bullae  formed  on 
the  soles,  leaving  raw  granulating  surfaces.  In  both  feet 
a  line  of  demarcation  formed  at  the  bases  of  the  third,  fourth 
and  fifth  toes,  which,  in  a  condition  of  dry  gangrene,  were 

The  accompanying  illustration  (Fig.  17)  shows  the 
condition  nine  months  after  the  onset.  Preventive 
ortiiopaedic  measures  have  been  employed  to  prevent 
pes  cavus  arising,  by  having  the  patient  wear  right- 
angled  tin  shoes  at  night. 


IV.  The  Surgery  of  War  Aviation. 

In  the  earlier  days  of  the  war  the  majority  of 
projectile  wounds  sustained  in  flying  were  due  to 
shrapnel  or  fragments  of  high  explosive  shell.  Later, 
with  the  institution  of  low  bombing,  and  low  flying 
attacks  on  infantry,  and  the  great  increase  in  the 
size  and  number  of  aerial  fights,  the  wounds  sustained 
were  mostly  due  to  bullets.  There  are  many 
instances  of  pilots  who  have  been  wounded  in  mid- 
air, yet  able  to  control  the  aeroplane  back  to  their 
own  aerodromes  ;  and  also  of  observers  who  although 
woimded  have  been  able  to  continue  the  fight,  or 
at  least  ward  off  hostile  machines  until  safety  was 
reached.  "  First  aid  "  dressing  packets  should  always 
be  carried  by  pilots  and  observers  engaged  in  war 
flying.  Much  could  be  done  to  safeguard  both  by 
providing  armour-plating  around  the  cockpits.  All 
varieties  of  gunshot  wounds  are  seen.  As  aerial 
fighting  is  carried  on  at  close  range  explosive  effects 
on  the  tissues  are  often  produced  by  bullets. 

Early  attention  is,  as  a  rule,  given  to  most  wounded 
aviators,  and  the  wounds  generally  are  fairly  clean 
and  tend  to  heal  quickly.  The  wounds  seen  at  the 
R.A.F.  Central  Hospital  during  the  past  year  have 
been  mostly  due  to  bullets,  and  the  parts  affected 
have  been  mainly  lower  and  upper  limbs.  There 
has  been  a  noticeable  absence  of  severe  infections, 
and  no  cases  of  gas  gangrene  have  occurred.  This  is 
explained  by  the  fact  that  the  wounds  rarely  come 
in  contact  with  the  earth  as  in  trench  warfare.  In 
the  latter,  especially  in  the  present  war,  fighting 
has  been  carried  on  over  highly  fertilised  and  culti- 
vated land,  the  soil  of  which  is  a  good  medium  for 
the  growth  of  anaerobic  and  gas-producing  organisms. 

One  case  of  bullet  w^ound  of  buttock  developed 
septicaemia,  and  the  streptococcus  was  grown  from 
the  blood.     The  wound  was  thoroughly  opened  up 


and  excised.  Carrel's  tubes  and  Eiisol  solution  ^vere 
used  locally.  Anti-strcptococcic  serum  was  injected 
subcutaneously  every  fourth  day.  Intramuscular  in- 
jections of  collosal  manganese  were  given,  and  thyroid 
extract  gr.  ii.  was  taken  by  the  mouth  twice  a  day. 
Recovery  was  slow  but  complete,  but  at  the  expense 
of  arthritis  of  both  wrists,  one  knee  and  the  opposite 

Fig.  17. — Showing  result  of  "  waterbite  '  to 
both  feet — nine  months  after  occurrence. 

liip  joint.     Although   now   these  complications  have 
improved  greatly. 

Compound  fractures  have  been  frequent,  and  in 
tliese  tlie  best  results  have  been  obtained  by  means  of 
extension  and  Eusol  solution  locally.  No  attempts 
have  been  made  to  plate  these  cases.  Sequestro- 
tomies  form  a  large  part  of  the  operative  work, 
and  the  use  of  B.I. P.P.  has  given  excellent  results 
in   tlu;   completion    of  these   operations.     The   latter 


are  not  to  be  performed  in  a  haphazard  way,  which 
often  consisted  in  a  mere  scraping  ot  a  sinus. 
Good  stereoscopic  X-ray  negatives  are  essential, 
and  after  a  careful  study  of  these,  the  affected  bone 
should  be  freely  exposed.  Only  in  this  manner  can 
all  dead  bone  be  removed.  B.I. P.P.  may  be  rubbed 
in  thoroughly,  but  it  rather  interferes  with  the  inter- 
pretations of  subsequent  skiagrams.  Eusol  solution 
for  two  days,  followed  by  saline  for  two  days,  gives 
excellent  results. 

The  most  difficult  problem  to  solve  is  the  treatment 
of  bone  cavities.  All  sequestra  must  be  removed, 
and  the  cavity  curetted,  dehydrated  with  alcohol, 
and  B.I. P. P.  rubbed  in.  At  a  later  operation  a 
muscle  flap  should  be  turned  into  the  cavity  if  possible. 
In  all  compound  fractures,  and  this  applies  to 
wounds  of  soft  parts  as  well,  special  attention  must 
be  paid  to  preventative  orthopaedic  measures  to 
avoid  contractures. 


Injuries  and  Destructive  Effects  of  Aeroplane 
Bombs  and  of  Aeroplane  Arrows,  with 
Suggestions     on     the     Precautions     to    be 

TAKEN     during     HOSTILE     AeRIAL     RaIDS 

A  large  part  of  the  work  in  this  chapter  is  based 
on  experience  of  air  raids  in  Belgium  and  France 
during  the  first  year  of  the  war.  In  conjunction 
with  Fleet  Surgeon  H.  V.  Wells,  R.N.,  the  observa- 
tions, up  till  February,  1915,  were  collected  together 
by  the  author,  and  published  in  the  "  British  Medical 
Journal,"  August,  1916. 

Since  that  time  aerial  bombing  became  more 
and  more  developed,  due  especially  to  the  advance- 
ment in  night  flying,  and  to  the  construction  of 
heavier  bombs  and  types  of  aeroplanes  to  carry  such  ; 
and  also  to  the  specialisation  in  bomb  practice,  and 
the  invention  of  more  accurate  sighting  methods. 

Types  of  Bombs 

Tlie  bombs  the  effects  of  which  were  observed  were 
of  two  kinds  : 

(a)  High  Explosive  Percussion  Bombs . 

The  high  explosive  bombs  weigh  from  10  to  20  lb., 
and  consists  of  a  metal  case  J  inch  thick,  filled  with 
liigh  explosive  only.  It  is  presumed  that  no  shrapnel 
bullets  are  contained  in  them,  as  the  autlior  has  never 
been  able  to  demonstrate  such  either  in  the  wounds  or 
in  tin    wreckage  of  property  produced.     By  visiting 




the  spots  immediately  after  the  explosions  he  has 
been  able  to  secure  various  pieces  of  the  bombs — ^for 
example,  the  handle,  the  base,  and  pieces  of  the 
casing  of  various  size,  as  shown  in  Fig.  18. 

Depending  on  the  object  to  be  destroyed  the 
modern  aeroplane  bomb  may  weigh  anything  up  to 
many    hundred   pounds.     The    destructive  effect    is 

lit;.  IS. — Showing  to  left,  handle  and  fragments  of  percussion  bomb; 
to  right,  part  of  an  incendiary  bomb. 

due  to  the  high  explosive  and  to  the  metal  case 
being  broken  up  into  fragments  ot  various  sizes,  which 
are  propelled  in  all  directions  at  tremendous  velocity. 
The  bombs  may  be  released  from  the  aeroplane  by 
hand,  either  over  the  side  of  the  machine  or  through 
a  hole  in  the  floor  of  the  fuselage,  or  by  a  special 
bomb-dropping  device,  by  means  of  which  the  bombs 
are  released  by  hand  levers  or  foot  pedals  from  a 
special  bomb-rack. 

As  the  bomb  leaves  the  aeroplane  a  pin  is  with- 



drawn,  wliich  allows  a  small  metal  propeller  to 
unscrew  itself ;  this  sets  the  internal  mechanism 
ready  for  explosion  on  contact.  As  a  precautionary 
measure  the  mechanism  is  not  set  ready  for  detona- 
tion until  the  bomb  has  fallen  about  200  feet.  Fixed 
steel  vanes  keep  the  bombs  steady  on  their  downward 
flight.  Sometimes  these  bombs  fail  to  explode  on 
percussion,  and  have   been  found  intact.     An  aero- 

I'lG.  19. — Showing  a  crash  after  a  bombing  raid.     The  arrow  points  to 
an  unreleased  bomb. 

plane  may  return  from  a  raid  with  an  unreleased 
bomb  on  its  rack.  Should  a  crash  occur  or  fire  break 
out  explosion  may  occur.     (Fig.  19.) 

{b)    Incendiary  Bombs. 

The  incendiary  bombs  used  to  set  fire  to  collec- 
tions of  stores,  etc.,  consist  of  a  thin  metal  casing 
containing  a  medium  soaked  in  some  highly  inflam- 
mable substance,  such  as  petrol.  A  percussion 
device  in  the  bomb  ignites  the  inflammable  contents. 


Flight  of  Bomb 

Bombs  are  dropped  from  aeroplanes  usually  at  a 
height  varying  from  4,000  to  7,000  feet.  Below  this 
the  machine  comes  well  within  the  danger  zone  from 
anti-aircraft  guns.  The  forward  speed  of  the  aero- 
plane determines  the  first  part  of  the  bomb's  flight, 
which  will  be  in  a  forward  direction  until  gravity 
asserts  itself,  and  then  the  course  will  be  directed 
downwards.  But  from  experience  the  author  ventures 
to  make  the  statement  that  there  is  a  certain  amoimt 
of  forward  deflection,  perhaps  small,  in  the  whole 
course  of  the  bomb's  flight.  Lateral  deflection  in 
the  bomb's  flight  may  also  occur,  and  this  may  be 
due  to  one  of  two  causes.  First,  if  the  wind  is  across 
the  aeroplane's  path  some  lateral  deflection  of  the 
bomb's  flight  must  be  expected,  depending  on  the 
wind  velocity  and  the  height  of  the  aeroplane  from 
the  ground.  Secondly,  if  a  bomb  is  released  as  the 
machine  is  being  banked  centrifugal  action  comes 
into  play  and  will  cause  some  lateral  deflection. 

A  bomb  was  dropped  from  an  aeroplane  at  about  6,000  ft.  A 
cross  wind  was  blowing  and  the  bomb  fell,  as  estimated  by  com- 
petent observers,  at  a  spot  200  yards  lateral  to  the  aeroplane  path. 

A  bomb  was  dropped  from  a  height  of  6,000  ft.  and  stnick  the 
front  of  a  house  in  a  narrow  street.  The  house  was  struck  at  the 
level  of  the  first  floor  ;  to  do  this  the  bomb  must  have  had  either 
forward  or  lateral  deflection. 

The  accuracy  of  bomb  dropping  is  thus  influenced 
by  many  factors — for  example,  height  of  aeroplane 
from  ground,  its  air  speed,  its  ground  speed,  wind 
velocity,  gravity,  etc.  ;  thus  the  chances  of  obtaining 
a  direct  hit  on  a  particular  object,  unless  this  be  large 
such  as  a  collection  of  troops  or  transport,  large 
buildings,  massed  shipping,  etc.,  are  rather  small. 

WTien  a  bomb  is  dropped  it  comes  rapidly  to  earth 
with  a  peculiar  hissing  shriek,  quite  unlike  the 
whistle  of  a  shell.     On  explosion  it  sends  up  a  cloud 

I'LAiL  li,.     .^Iiuuiii-  ilic  t\i.l(,M\i-  t  lie,  I  (,l'  a  large  norial  Ijoiiili 


of  smoke  and  debris  many  feet  high.  For  some  time 
past  low  bombing  lias  become  quite  a  feature  of 
aerial  warfare. 

These  arc  much  akin  to  the  injuries  produced  by 
conmion  high  explosive    shells.     Death    or    more    or 
less   severe    injuries    may    be    due   to   the    following 
causes : — 

From  the  Actual  Shock  of  the  Explosion. 

That  is  the  effect  produced  on  the  individual  by 
the  disturbance  in  the  air,  created  by  the  sudden 
expansion  of  the  contents  of  the  shell. 

{a)  The  shock  may  actually  kill  without  producing 

any  visible  destruction  of  tissue. 

Tw  o  civilians  were  found  lying  dead  5  ft.  from  a  hole  in  the  street 
made  by  a  bomb.  There  was  shght  frothing  at  the  mouth,  but  no 
wounds,  fractures,  bums,  or  any  \isible  injuries. 

{b)  The  explosion  may  blow  off  limbs,  or  shatter 
them  severely,  or  cause  multiple  wounds.  The 
traumatic  shock  in  all  these  cases  is  very  severe,  and 
many  cases  never  rally. 

A  number  of  civilians  were  standing  round  one  of  the  AUies' 
aeioplanes  when  a  bomb,  which  was  being  handed  up  by  a  mechanic 
to  the  obsen'or,  fell  and  for  some  unexplained  reason  exploded. 
Six  people  were  instantly  killed.  All  had  compound  fractures, 
some  severely  shattered  limbs,  whilst  others  had  the  whole  or  a 
portion  of  an  extremity  blown  off.  Curiously  enough,  the  mechanic 
escaped  with  nothing  more  than  a  Avound  of  the  forehead,  A\hilst 
the  observer,  Asho  \\as  thrown  30  ft.  in  the  air,  came  down  un- 
hannod,  except  for  slight  wounds  of  face  and  ami,  due  to  small 
fragments  of  the  bomb.  Hci  suffered  in  no  way  from  shock,  and 
was  able  to  walk  into  hosi)ital  unaided. 

A  })<)mb  cx])I()dcd  5  ft.  from  a  Belgian  ofhcer.  He  sustained  a 
com])ound  comminuted  fracture  of  the  left  leg  and  two  deep  wounds 
on  the  front  of  l>oth  thighs.  The  shock  was  very  marked,  and  he 
died  the  same  night.  On  opening  up  the  thigh  wounds,  no  frag- 
ments of  ])ombs  or  shrapnel  bullets  were  found.  The  wounds  w  ere 
due  U)  explosive  effect  alone. 

A  boml)  explofled  a  few  feet  from  the  following  cas(!s,  the  injuiies 
received  being  due  to  exi)losive  effect  :    A  civilian,  aged  40,  had  a 


■wound  exposing  the  muscles  of  the  neck  r,nd  trachea,  and  a  com- 
pound comminuted  fracture  of  the  left  leg.  Amputation  of  the 
leg  was  perfoi-med,  but  he  died  shortly  afterwards.  A  boy  who 
had  compound  fracture  of  femur  and  severe  shock  never  rallied, 
and  died  the  same  night. 

From  Flying  Fragments  of  Bomb. 

Tlie  pieces  into  which  a  20  lb.  bomb  bursts  are 
never  very  large,  the  largest  being  2  inches  by  2  inches, 
Avhilst  many  are  quite  small.  Persons  standing 
Anthin  30  feet  of  the  explosion  are  likely  to  be 
injured.  Beyond  that  range  the  chances  of  escape 
are  much  increased,  but  a  flying  fragment  may  injure 
severely  at  150  feet  from  the  explosion. 

A  civihan  standing  30  ft.  from  a  bomb  explosion  received  a  large 
\\ound  in  the  abdominal  Mall  from  a  flying  fragment.  Viscera 
protnided,  and  he  died  a  few  hours  after  admission  to  hospital. 

A  woman,  about  20  ft.  distant,  had  a  perforating  wound  of 
thorax  and  penetrating  MOimds  of  abdomen  and  right  tliigh.  She 
died  on  the  way  to  hospital. 

A  man,  about  40  ft.  distant,  received  a  penetrating  Avound  of 
abdomen.  Xo  exit  A\ound  discovered.  He  A\as  operated  on,  but 
the  fragment  Avas  not  foimd  at  the  time.  He  died  later  of  general 

A  AAoman,  30  ft.  distant,  received  a  flying  fragment  in  the  left 
side  of  the  chest.     Further  history  unknown. 

A  A\oman,  standing  30  feet  from  a  bomb  explosion,  received 
nmltiple  Avounds  from  small  fragments  as  folloA\s  :  Small  pene- 
trating Avounds  of  left  foot,  left  thigh,  right  arm,  left  breast,  and 
left  eyelid.     A  left  metatarsal  bone  Avas  fractured. 

At  a  distance  of  50  to  60  feet  from  where  a  bomb 

exploded  flying  fragments  entered  a  cellar  (many  of 

the  Continental  cellars,  although  underground,  have 

part    of   the    door,    window,    or    grating    above    the 

street  level)  and  wounded  three  people — 

A  Avoman  received  a  wound  on  left  breast. 
A  Avoman  received  a  deep  Avound  of  thigh. 
A  child  received  a  slight  Avound  of  breast. 

From  Burns. 

Signs   of  burning   and   charring   are   rarely  found 
alone,  and  are  usually  accompanied  by  other  more 


serious  injuries.     \Mien  present  they  only  occur  to 
those  in  close  proximity  to  the  explosion. 

A  bomb  exploded  ?,bout  5  feet  from  v,  soldier,  shattering  his  left 
leg,  fracturing  the  right  tibia,  cutting  his  lip  and  nose,  and  causing 
superficial  bums  all  over  the  body.     He  died  soon  after  admission. 

A  soldier  in  a  stooping  position  a  few  feet  from  where  a  bomb 
fell  had  his  left  buttock  blown  off  and  the  wound  absolutely  charred. 
This  case  did  extremely  well. 

Fro77i  Fumes. 

Although  the  author  has  no  cases  among  his  records 
it  is  quite  possible  that  the  fumes  given  off  at  the  time 
of  the  bomb  explosion  might  have  a  fatal  or  stupefy- 
ing effect  on  those  in  the  near  vicinity. 

From  Chemicals. 

As  far  as  can  be  ascertained  no  evidence  of  the 
use  of  chemicals  in  aeroplane  bombs  dropped  by  the 
enemy  exists  up  till  June,  1917.  Then  after  certain 
hostile  air  raids  in  that  month  many  cases  of 
dermatitis  were  reported  due  to  contact  with  a 
brownish  powder  either  coating  the  bombs  or 
liberated  by  the  bomb  explosion.  Cases  were  re- 
ported in  the  "  British  Medical  Journal  "  of  July 
and  August,  1917,  by  Drs.  Sequeira,  J.  W.  Tyson, 
H.  G.  Adamson,  and  J.  M.  H.  MacLeod. 

Dr.  Sequeira  saw  fifty-nine  cases  of  dermatitis — 
thirty-five  in  males  and  twenty-four  in  females — due 
to  their  coming  in  contact  with  a  brown  powder 
which  was  scattered  about  in  the  neighbourhood  of 
})ombs  dropped  during  a  certain  hostile  air  raid. 
In  his  eases  the  initial  staining  was  of  an  orange 
tint — well  seen  on  the  palms,  followed  about  nine 
days  later  by  intense  irritation  and  itching  wliicli 
interfered  with  sleep.  Closely  set  discrete  vesicles, 
about  tlie  size  of  hemp  .seeds,  appeared,  more  especially 
on  the  palms  and  sides  of  tlie  fingers.  Not  much 
redness  was  noted,  but  the  backs  of  the  hands  were 


swollen.  The  eruption  increased,  and  reached  its 
height  about  the  fourth  day  from  its  appearance. 
Blebs,  filled  with  clear  fluid,  occurred — some  as  large 
as  a  hen's  egg.  Infection  followed  and  pustules 
formed.  The  epidermis  separated,  leaving  raw, 
rather  dry,  red  surfaces.  There  was  slight  pyrexia 
in  some  cases  to  100^  F.  From  the  bacteriological 
examination  the  fluid  in  the  early  vesicles  was  found 
sterile.  Dr.  Panton  found  an  eosinophilia  present. 
The  chemical  irritant  in  the  brown  powder  was 
found  to  be  hexa-nitro-diphenyl-amine,  which  is 
recognised  as  an  explosive  agent  often  mixed  with 

Dr.  Sequeira  found  the  best  treatment  was  the 
application  of  calamine  liniment  to  the  affected 
parts  ;  and  he  advised  the  use  of  wet  alkaline  rags 
in  the  handling  or  removal  of  the  powder,  and  the 
avoidance  of  ordinary  gloves  as  a  protective  measure. 

From  Wreckage  Displaced  by  Bombs. 

The  injuries  thus  received  so  far  have  been  slight, 
and  have  been  due  to  falling  stones,  bricks,  mortar, 
etc.  The  usual  20  lb.  aeroplane  bomb  is  not  suffi- 
ciently powerful  so  to  wreck  an  ordinary  house  that 
the  wreckage  falling  would  cause  severe  injuries. 
Most  of  the  injuries  have  been  slight  bruises,  and  no 
deaths  have  been  recorded,  but  with  the  much 
heavier  type  of  bomb  used  the  wreckage  displaced 
may  be  considerable,  resulting  in  severe  or  fatal 

From  Accidents. 

These  occur  to  individuals  in  their  hurry  to  escape 

from  danger  from  above. 

A  bomb  fell  in  the  narrow  street  of  a  French  town,  when  a  woman 
with  a  child  in  her  arms  (some  50  yards  away)  made  a  wild  leap 
for  safety,  fell  down  some  cellar  steps,  and  crushed  her  child  to 


In  the  stampede  and  panic  among  an  alien  mob 
many  deaths  from  crushing  have  ensued.  Again, 
tliere  is  no  doubt  that  the  crowding  together  of 
many  individuals  in  underground  areas  has  increased 
the  spread  of  zymotic  diseases. 

From   Anti-aircraft  Missiles. 

During  hostile  aerial  raids  the  air  positively  teems 
Avith  metal  from  all  kinds  of  anti-aircraft  guns,  and 
the  danger  to  curious  and  ignorant  onlookers  from 
falling  missiles  is  very  great.  It  is  surprising  that 
so  few  have  been  injured  from  this  cause,  and  the 
number  of  escapes  have  been  truly  wonderful. 
The  base  of  a  75  nmi.  shell,  weighing  3|  lb.,  came 
down  very  close  to  one  of  our  officers,  and  had  it 
struck  would  have  caused  instant  death.  The 
missiles  that  are  likely  to  return  from  the  air  during 
the  defence  are  : 

1.  Bullets  from  rifles  and  machine  guns.  These  come  down 
with  surjirising  velocity,  sufficient  to  kill  or  injure  severely.  Some 
have  ]>cen  found  imbedded  in  woodwork,  and  others  with  their 
noses  turned  or  flattened,  due  to  the  tremendous  impact  on  the 

2.  Pieces  of  shell,  of  vr.rying  size,  and  shrapnel  bullets  from 
proper  anti-aircraft  guns. 

3.  Bases  and  pieces  of  common  shell,  solid  shell,  and  unexploded 

Fig.  20  shows  the  base  of  a  French  75  mm.  shell 
and  a  large  portion  of  a  shrapnel  bursting  shell. 
Th(y  came  down  together  with  French  mitrailleuse 
l)ullets  in  the  outskirts  of  a  town  during  a  hostile 
aerial  raid. 

Range  of  Bomb  Fragments 

The  author's  observations  on  the  first  series  of  20  lb. 
l)ombs  dropped  showed  that  most  of  the  fragments 
were  driven  upwards  at  about  an  angle  of  .30  degrees, 
so  that  an  individual  lying  flat  on  the  ground  in  the 
neighbourhood  would  probably  escape  unhurt.     These 


bombs  also  made  a  fairly  deep  hole  in  the  ground,  as 
a  rule  about  2  J  feet  deep.  Latterly  the  bombs  dropped 
have  exploded  so  that  the  fragments  have  been 
driven  along  parallel  to  the  ground,  as  well  as 
upwards  to  an  angle  of  60  degrees.  Bomb  fragments 
have  been  found  embedded  in  walls  at  a  distance  of 
150  feet  from  the  explosion. 

Destructive  Effects 

These  have  been  noticed  on  streets,  houses,  sheds, 
sand,  and  shipping  : 

(a)  Streets. — With  regard  to  the  effects  of  20  lb. 
bombs  the  hole  produced  is  2  or  3  feet  wide  and  1 J  to 
2  feet  deep.  Windows  in  the  neighbourhood  for  50  to 
100  yards  around  are  shattered.  A  plate-glass  window 
40  feet  from  a  bomb  explosion  showed  multiple 
stellate  fractures,  a  frost-like,  arborescent  appearance 
being  produced.  Wooden  shutters  and  doors  at 
30  feet  distance  have  been  perforated,  while  in 
others  bomb  fragments  have  been  found  embedded. 
Pieces  have  been  driven  along  parallel  to  the  ground 
in  through  (Continental)  cellar  doors  and  windows, 
injuring  people  within.  A  bomb  bursting  in  the 
street  would  send  fragments  through  the  ground 
floor  and  first  floor  windows,  but  not  through  the 
masonry.  Safety  lies  in  keeping  against  the  wall, 
indoors  on  the  ground  floor,  out  of  the  line  of  windows. 

(b)  Houses. — The  usual  20  lb.  bomb  employed 
from  an  aeroplane  will  go  through  an  ordinary  roof 
and  explode  in  the  top  room.  We  have  not  found 
one  which  has  penetrated  further.  A  wire  splinter- 
proof  netting  would  cause  the  bomb  to  explode 
outside,  and  only  some  fragments  would  probably 
come  through  the  roof.  Sand  also  acts  as  a  good 
protective,  but  its  weight  precludes  its  use  on  most 
roofs.  Very  few  houses  could  withstand  a  direct 
hit  from  a  heavy  bomb. 


A  bomb  came  through  the  roof  of  au  ordinary  dweUing-house 
and  exploded  in  the  top  room,  wrecking  everything  in  it,  but  no 
fragments  penetrated  the  floor  below. 

A  bomb  stnick  the  projecting  ledge  of  a  house  roof  and  burst, 
dislodging  some  tiles  and  bricks,  bloA\  ing  in  the  windows,  damaging 
property  in  the  upper  rooms,  and  the  fragments  spent  themselves 
in  the  street  below,  kiUing  two  soldiers  who  had  taken  protection 
in  a  doonvay.     Such  doorways  and  passages  afiford  little  j)rotection. 

Fig.  20. — Showing  pieces  of  anti-aircraft  missiles  which  fall  during 
an  air  raid  and  may  produce  serious  injuries. 

A  Ijuml).  with  either  a  forward  or  lateral  deflection,  stnick  the 
front  of  a  house  and  destroyed  a  good  deal  of  the  masonry,  and 
wrcckcrl  furniture,  etc.,  within.     Fortunately  no  one  was  injured. 

(c)  Sheds. — The  glass  and  wooden  roof  of  a  large 
shed  (a  hangar)  was  pierced  by  a  bomb,  which  must 
have  exploded  just  after  entry.  The  fragments  were 
driven  downwards,  perforating  in  many  places  a 
canvas  covering,  and  killing  two  people  below.  No 
others  were  injured. 

{d)  Sand. — We  have  records  of  six  bombs  exploding 
on   a   sandy   beach.     The   hole   produced   is   usually 


3 1  to  4|  feet  wide,  and  1  to  2  feet  deep.  Case  frag- 
ments are  found  embedded  in  the  sides  of  the  crater. 
On  explosion  a  spray  of  wet  sand  is  carried  laterally 
for  a  distance  of  30  feet.  Bags  full  of  sand  form  an 
ideal  protection  on  a  bomb-proof  shelter. 

{e)  Shipping. — A    bomb    fell    on    a    barge,    and^ 
exploding,  made  a  hole  in  it,  causing  it  to  sink  rapidly. 

Precautions  to  be  taken  during  Hostile  Aerial  Raids 
On  headquarters  being  notified  of  the  approach  of 
enemy  aircraft,  warning  signals  should  be  given  to 
the  commioiity,  such  as  the  firing  of  a  gun,  or  maroons 
in  the  case  of  air  raids  at  night,  hoisting  of  a  flag 
on  the  town-hall,  blowing  of  a  ship's  siren,  use  of  a 
military  rattle,  etc.  Orders  should  be  given  before- 
hand that  all  except  those  connected  with  anti- 
aircraft defence  must  seek  cover  indoors,  preferably 
in  basement  cellars,  or,  failing  these,  on  the  ground 
floors,  away  from  the  line  of  windows.  "  Get  in 
and  get  under  "  is  the  motto  for  safety.  It  must  be 
remembered  that  it  is  extremely  difficult  for  the 
onlooker  below  to  gauge  with  any  accuracy  the 
position  of  the  aeroplane  relative  to  his  position 
on  the  ground.  The  danger  zones  are,  as  a  rule, 
immediately  in  front  of,  and  lateral  to,  the  approach- 
ing aeroplane  ;  the  areas  of  safety  lie  directly  behind 
its  flight.  But  it  must  not  be  forgotten  that  a  well- 
banked  turn  may  quickly  alter  the  aeroplane's 
direction  and  so  place  an  individual  below  in  the 
danger  area.  Fire  stations  should  be  notified,  and 
doctors,  first-aid  crews,  and  ambulances  made  ready 
on  telephonic  communication.  School  children 
should  not  be  sent  home  from  school  but  congregated 
on  the  ground  floors  out  of  the  line  of  windows. 
If  people  flock  into  the  streets  to  watch  events,  they 
are  exposed  to  as  much  danger  from  falling  anti- 
aircraft  missiles   as   from   the   enemy's   bombs,    and 


needless  casualties  will  ensue.  On  no  account  must 
iniexploded  bombs  be  handled  or  touched  ;  a  guard 
should  be  put  over  them  and  the  nearest  authorities 
notified.  Houses  that  require  to  be  specially  pro- 
tected should  have  a-  splinter-proof  netting  arranged 
over,  and  some  feet  above,  the  roof.  This  "vvould 
cause  some  bombs  to  explode  outside  the  roof,  and 
only  a  few  fragments  would  probably  penetrate  the 
roof.  Sand  in  bags  can  be  used  if  its  weight  can  be 
sustained.  As  hospital  ships  must  at  times  be  in 
ports  which  are  liable  to  aerial  attacks,  we  recom- 
mend that  such  ships  as  have  their  wards  directly 
under  the  upper  deck  should  make  use  of  a  similar 
splinter-proof  netting.  In  houses  the  best  protection 
is  afforded  by  underground  cellars,  especially  those 
built  under  the  footpath  and  not  directly  under  the 
house.  In  Continental  cellars,  which  are  partly 
above  the  street  level,  people  are  safe  if  they  keep 
away  from  the  cellar  window,  door,  or  grating,  as 
the  case  may  be.  The  same  applies  to  the  groimd- 
floor  room  of  an  ordinary  house.  Avoid  upper 
rooms,  windows,  and  doorways.  In  the  street, 
passages  and  entrances  to  shops,  etc.,  afford  no  pro- 
tection, and  are  to  be  avoided.  If  a  passage  open 
at  both  ends  is  one's  only  shelter,  it  is  better  to  take 
the  centre  of  it  and  lie  down. 

The  precautions  to  be  taken  in  buildings  where 
there  are  more  or  less  large  collections  of  people, 
such  as  factories,  schools,  works,  barracks,  etc., 
depend  upon  the  size  and  type  of  the  building. 
When  there  are  upper  stories  the  individuals  should 
)je  collected  on  the  ground  floor,  with  the  same  pre- 
cautions as  for  a  house.  When  there  are  no  upper 
stories  and  the  building  has  a  ground  floor  only — 
for  example,  a  hangar  or  some  hospitals — those 
locally  in  authority  should  sec  if  there  is  in  the 
neighbourhood  another  building  affording  protection. 


If  SO,  arrangements  should  be  made  for  occupying 
this  on  hearing  the  warning  signal,  and  this  should 
be  practised  and  carried  out  as  for  fire  drill,  to  avoid 
panic,  especially  so  with  school  children.  If  no  such 
safety  building  exists,  the  best  measure  to  adopt 
is  to  build  beforehand  some  type  of  bomb-proof 
shelter  within  the  building.  We  have  seen  a  very 
good  one  made  in  the  large  shed  of  a  works  from  the 
available  material  present.  The  sides  consisted  of 
tins  or  drums  containing  sand  or  non-inflammable 
merchandise,  the  roof  was  of  timber  supported  by 
powerful  props,  and  on  the  top  of  this  were  placed 
bags  of  sand  1  foot  thick.  This  is  almost  certain, 
we  think,  to  keep  out  all  fragments  of  a  bomb 
exploding,  as  it  would,  just  inside  the  roof  of  the 
shed.  Provision  should  be  made  for  the  interior 
lighting  of  all  bomb-proof  shelters,  as  a  dark  place 
crowded  with  people,  who  may  be  already  in  a  high 
state  of  excitement,  is  conducive  to  panic.  Inhabit- 
ants in  towns  subject  to  air  raids  paste  broad  strips 
of  paper  diagonally  over  the  inside  of  their  windows, 
thus  preventing  glass  falling  outward  and  injuring 
people  below. 

Aeroplanes,  as  well  as  airships,  can  be  and  have 
been  used  on  many  occasions  during  this  war  for 
making  aerial  attacks  by  night.  The  author  has  had 
the  experience  of  such  enemy  raids.  A  point  worth 
remembering  is  that  on  a  bright,  clear,  moonlight 
night  an  aeroplane  is  extremely  hard  to  see,  and 
almost  everything  is  in  the  enemy's  favour.  The 
pilot  can  see  well  and  cannot  be  seen  ;  he  can  fly 
fairly  low  and  thus  make  more  accuracy  in  bomb- 

Injuries  £rom  Aeroplane  Arrows 

During  the  time  the  author  was  working  on  the 
effects  of  aeroplane  bombs  he  tried  to  find  cases  with 


injuries  resulting  from  aeroplane  arrows  or  flechettes. 
lie  could  only  find  one  doubtful  case  in  an  Indian 
hospital  where  one  patient  said  he  thought  "  some- 
thing came  down  from  above  and  pierced  his  hand." 
Very  early  in  the  war  Dr.  J.  Volkmann  read  a 
paper  on  aeroplane  arrow  injuries  before  a  special 
meeting  of  the  Stuttgart  Medical  Society.  It  seems 
that  three  companies  were  bivouacking  at  intervals 
of  eight  paces  whilst  two  of  our  aeroplanes  were 
overhead  at  a  height  of  3,000  to  5,000  feet,  when 
suddenly  one  soldier  felt  a  stabbing  pain  in  his  foot, 
and  found  that  a  small  steel  arrow  had  penetrated 
it.  Cries  of  pain  arose  all  around,  the  horses  becaine 
restive  a  ad  two  were  hit.  About  fifteen  soldiers 
in  all  were  hit.  Fifty  arrows  had  been  dropped 
so  that  one  in  every  three  found  a  mark.  One  soldier 
was  pinned  to  the  ground  by  an  arrow  passing 
tlirough  his  foot,  another  required  an  incision  for 
liberation  of  the  arrow  from  the  leg.  In  one  case 
a  penetrating  scalp  wound  was  caused  without 
injury  to  skull.  In  another  instant  death  was 
caused  by  the  arrow  entering  the  left  temple,  and 
out  again  by  the  right  coronary  suture.  Another 
death  was  caused  by  the  arrow  entering  at  the 
slioulder  and  passing  into  the  thoracic  cavity.  In 
one  case  there  was  a  wound  of  cheek  penetrating  the 
mouth.  Most  of  the  cases  did  well  under  iodine  and 
dry  dressings. 


Aeroplane  Dope  Poisoning 

Although  the  prevention,  early  recognition,  and 
treatment  of  aeroplane  dope  poisoning  are  of  more 
importance  to  the  medical  officers  attached  to  air- 
craft production  factories  than  to  those  stationed  at 
aerodromes  it  is  nevertheless  well  that  the  latter 
should  be  informed  on  the  subject.  In  factories  for 
the  production  of  aircraft,  doping  is  employed  on 
an  extensive  scale,  being  carried  on  more  especi- 
ally by  female  labour — at  an  air  station  or  flying 
school  on  the  other  haad  the  aeroplanes  that  survive 
any  lengtli  of  time  have  to  be  redoped  every  now  and 
then.  A  certain  number  of  mechanics  are  detailed 
off  for  this  work,  and  the  medical  officer  is  usually 
consulted  with  regard  to  their  selection.  He  must 
have  them  continually  under  observation  in  order 
to  step  in  at  the  earliest  possible  moment  when 
dope  poisoning  symptoms  appear ;  and  he  also 
has  to  inspect  and  advise  on  any  matters  relating  to 
construction,  ventilation,  or  general  hygiene  of  the 
doping  sheds. 

Aeroplane  varnish,  or  dope  as  it  is  commonly 
called,  is  applied  to  the  fabric  covering  the  wings 
and  body  of  an  aeroplane,  in  order  to  keep  the  fabric 
smooth,  evenly  stretched  and  impervious  to  air  and 
especially  moisture.  The  wing  fabric  of  a  new  aero- 
plane receives  about  six  coats,  and  each  coat  is 
allowed  to  dry  before  the  next  one  is  applied. 

The  doping  has  to  be  done  in  a  warm  atmosphere, 



about  65°  F.,  so  that  the  fabric  may  not  be  affected 
by  dampness  and  subsequent  rotting. 

Dope  consists  of  acetate  of  cellulose  dissolved  in 
acetone,  carbon  tetrachloride,  benzene,  methylated 
spirit,  and  tetrachlorethane.  The  various  dopes 
employed  vary  in  the  proportions  of  their  con- 
stituents. Dope  is  a  syrup-like,  colourless  liquid, 
smelling  somewhat  like  chloroform.  \Mien  applied 
to  fabric  it  dries,  leaving  a  firm,  flexible,  waterproof, 
and  airtight  coating.   Dope  vapour  is  heavier  than  air. 

During  the  latter  part  of  1914,  and  owing  to  the 
stimulus  applied  to  aircraft  production  by  the  war, 
quite  a  number  of  cases  of  illness  with  a  definite 
train  of  symptoms  were  noted  amongst  those 
engaged  in  aeroplane  doping,  and  some  deaths  were 
recorded.  It  was  found  by  the  researches  of  Drs. 
AV.  H.  Willcox,  B.  IT.  Spilsbury.  and  T.  M.  Legge 
that  the  poisonous  constituent  of  dope  was  tetra- 
chlorethane. This  was  proved  by  exposing  animals 
to  the  fumes  of  dope,  acetone,  methylated  spirit, 
benzene  and  tetrachlorethane  separately.  The 
animals  that  were  exposed  to  dope  and  tetrachlore- 
thane were  the  only  ones  affected.  Those  exposed 
to  tetrachlorethane  showxd  more  marked  signs  and 
symptoms  than  those  exposed  to  dope. 

Tetrachlorethane  CaHaCIi  is  a  colourless  liquid 
witli  a  specific  gravity  of  1.614  and  a  boiling  point  of 
147°  ;  it  has  strong  anaesthetic  properties,  and  is 
a  powerful  tissue  poison,  especially  selecting  and 
attacking  liver  and  kidney  tissues.  It  is  a  solvent 
of  resins,  is  not  inflammable,  and  is  comn)ereially 
fairly  cheap.  These  latter  properties,  combined  witli 
the  fact  that  if  tetrachlorethane  is  eliminated  from 
dope,  the  resulting  coating  on  the  fabric  is  not 
nearly  so  tight,  flexible,  and  durable,  explain  its 
value  as  a  constituent  of  dope.  As  a  rule  dope 
contains  about  12  per  cent,  of  tetrachlorethane. 


Those  employed  in  doping  may  suffer  from  a 
definite  train  of  signs  and  symptoms  due  to  inhala- 
tion of  tetrachlorethane  vapour  ;  and  it  is  possible 
that  the  toxaemia  and  tissue  changes  so  set  up  may 
end  in  fatal  results.  The  author  has  never  had  any 
fatal  cases,  but  by  bi-weekly  inspection  of  the 
mechanics  employed  he  has  been  able  to  diagnose  the 
early  onset  of  poisoning  in  some  cases.  His  experience 
has  been  that  one  of  the  earliest  symptoms  is  loss  of 
appetite  with  a  marked  distaste  for  food,  accom- 
panied by  constipation,  and  a  feeling  of  nausea, 
especially  noticed  in  the  early  morning.  Dr.  F. 
Barlow,  on  the  other  hand,  insists  that  pain  in  the 
back  is  one  of  the  earliest  symptoms.  In  his  cases 
this  pain  was  persistent  and  increased  in  severity 
as  the  day  went  on  so  that  in  some  cases  work  had 
to  be  interrupted.  The  urine  as  a  rule  becomes 
darker  in  colour  each  day,  and  albumen  may  be 
noted.  A  common  symptom  is  dryness  of  the 
mouth  and  a  peculiar  taste  at  the  back  of  the  throat, 
whilst  the  tongue  is  usually  noted  to  be  heavily 
coated.  Malaise,  drowsiness,  and  gradually  increas- 
ing weakness  follow.  Headaches  may  be  prominent 
among  these  symptoms.  Jaundice  sets  in,  is  pro- 
gressive, and  is  usually  noticed  first  by  the  worker's 
comrades.  The  stools  become  clay-coloured,  and  vague 
abdominal  pains,  tenderness  and  feeling  of  heaviness 
over  the  hepatic  area  may  be  found.  If  the  patient 
is  at  this  stage  removed  from  doping  and  appro- 
priately treated  all  signs  and  symptoms  may  dis- 
appear. The  clearing  up  is  gi'adual,  and  may  take 
some  weeks.  On  the  other  hand  if  doping  is  con- 
tinued the  signs  and  symptoms  increase  in  severity  ; 
the  jaundice  is  progressive,  there  is  increasing  weak- 
ness, itching  of  the  skin,  vertigo,  and  delirium,  and 
the  patient  passes  into  a  comatose  state  and  finally 
death    ensues.     Willcox,    in    his    valuable    work    on 


Dope  Poisoning,  noted  in  the  early  stage  of  the 
disease  a  slight  enlargement  of  the  liver  with  later 
on  a  eontraetion ;  bile,  a  trace  of  albumen  and 
numerous  casts  in  the  urine,  but  no  acetone  or 
diacetic  acid.  He  states  that  if  marked  jaundice 
is  present  the  prognosis  is  bad,  and  points  out  the 
following  interesting  clinical  and  diagnostic  features. 
{a)  The  insidious  onset  of  the  symptoms. 

(b)  The  comparatively  long  duration  of  the  acute 
stage  when  marked  jaundice  has  supervened,  thus 
distinguishing  the  cases  from  acute  yellow  atrophy 
of  the  liver. 

(c)  The  absence  of  marked  pyrexia,  thus  distin- 
guishing the  cases  from  infective  jaundice. 

{d)  The  absence  of  anaemia,  thus  distinguishing 
the  cases  from  poisoning  by  poisons  which  cause 
marked  blood  destruction,  e.g.  arseniuretted  hydrogen. 

{e)  The  marked  character  of  the  jaundice,  Avhich  is 
much  deeper  than  is  usually  seen  in  cases  of  delayed 
chloroform    poisoning. 

Barlow  raises  the  question  that  there  may  be 
a  pseudo  form  of  dope  poisoning  of  a  hysterical 
or  auto-suggested  type,  especially  amongst  female 
workers.  In  Germany  quite  a  distinct  type  of  dope 
poisoning  was  noted,  chiefly  characterised  by  nervous 
symptoms,  such  as  headache,  tremor,  numbness,  etc. 

Many  individuals  have  worked  at  doping  for  quite 
long  periods  without  being  affected  ;  and  there  is 
no  doubt  that  some  are  much  more  susceptible  than 
others  to  the  poisonous  effects  of  tetrachlorethanc. 

The  pathological  aspects  of  dope  poisoning  have 
been  investigated  by  Dr.  B.  II.  Spilsbury,  both  in 
the  human  body  and  in  animals.  In  one  case  the 
internal  organs  were  found  bile  stained,  whilst  this 
was  absent  in  otlier  two  eases.  The  chief  patho- 
logical changes  were  found  in  the  liver,  kidneys, 
and  heart  ;  and  the  changes  found  especially  in  the 


liver  varied  with  the  duration  of  the  disease.  Micro- 
scopically there  was  found  fatty  degeneration  of 
liver  cells  commencing  in  the  central  zones  and 
spreading  peripherally  through  the  lobules  and 
followed  by  necrosis.  Depending  on  the  duration  of 
the  disease  the  necrosis  was  followed  by  fibrosis — 
an  attempt  fit  repair — but  the  fibrotic  changes  so 
interfered  with  the  function  of  the  liver  that  a  fatal 
result  ensued.  The  heart  showed  dilatation  and 
fatty  degeneration  of  the  cardiac  muscle.  The 
kidneys  were  enlarged,  and  fatty  degeneration  had 

Treatment. — As  these  cases  show  symptoms  similar 
to  acidosis,  Barlow  treats  them  by  attempting  to 
obtain  alkaline  saturation  of  the  tissues — an  alkaline 
mixture  is  ordered,  containing  sod.  bicarb.,  magnes. 
carb.,  bismuth  carb.,  and  liquid  paraffin.  The 
patient  is  removed  from  doping,  put  to  bed  on  a  milk 
diet,  and  given  saline  aperients.  The  patient  should 
not  be  allowed  to  return  to  work,  if  at  all,  until  at 
least  a  month  after  the  complete  disappearance  of 
the  jaundice. 

Prophylaxis. — This  is  of  the  utmost  importance, 
considering  the  seriousness  of  the  disease.  In  select- 
ing mechanics  for  this  work  the  medical  officer  should 
see  that  they  are  all  healthy  and  that  they 
are  dentally  clean.  These  workers  should  be  in- 
spected twice  a  week  or  oftener  if  possible — a  special 
dope  book  should  be  kept  in  which  the  examination 
results  are  noted  each  time.  There  is  no  reason 
why  a  prophylactic  dose  of  sodium  bicarbonate 
and  glucose  should  not  be  given  to  these  dope  workers 
each  day.  They  should  also  be  instructed  as  to  the 
necessity  of  preventing  constipation.  They  should 
be  given  a  short  lecture  on  the  salient  points  con- 
nected with  dope  poisoning  so  that  they  can  take 
all  precautions  and  report  immediately  if  they  feel  out 


of  sorts. .  The  author  has  never  found  an}'  of  the 
mechanics  employed  in  doping  abuse  this  knowledge. 

There  should  be  a  special  doping  shed,  fitted 
with  exhaust  fans  at  the  ground  level,  so  as  to  carry 
off  the  dope  vapour,  which  is  heavier  than  air.  The 
doping  of  a  plane  should  be  begun  at  the  end 
nearest  the  fan — no  other  work  should  be  carried 
out  in  the  doping  shed — and  strict  orders  should  be 
issued  that  no  meals  are  to  be  eaten  there.  If 
weather  permits  doping  is  better  carried  on  out  of 
doors  in  the  summer-time. 

If  possible  it  is  better  from  the  administrative 
point  of  view  not  to  allow  a  certain  batch  of 
mechanics  to  work  at  doping  over  too  long  a  period, 
but  to  have  them,  say  after  a  two  months'  spell, 
detailed  for  other  work,  and  a  new  batch  put  on 
(loping,  thus  working  in  bi-monthly  relays. 


Aerobatics.— The  performance  of  trick  or  exhibition- 
flying,  such  as  looping,  spinning,  rolling,  cartwheels,  etc., 
also  kno\Mi  as  stunting. 

Aeroplane. — A  heavier-than-air  flying  machine,  supported 
hy  the  action  of  air  on  fixed  planes. 

Ailerons.- — ^Hingcd  flaps,  at  the  trailing  edge  of  the  Aving 
tips,  and  part  of  the  main  planes.  They  are  used  to  maintain 
the  aeroplane  on  a  level  keel,  and  to  bank  the  aeroplane 
in  turning.  They  are  put  in  use  by  movements  of  the  control 

Air  Pocket.— a  disturl)ance  in  the  air  causing  the  machine 
to  undergo  a  bump  or  drop. 

Air  Speed.- — -The  speed  of  the  machine  through  the  air. 

Air  Speed  Indicator. — An  instrument  for  registering  the 
speed  of  the  machine  through  the  air. 

Altimeter. — An  instrument  for  indicating  the  height 
of  the  machine  from  the  ground  where  it  started  from. 

Backwash.- — The  disturbed  air  in  the  wake  of  a  machine 
in  flight. 

Bank,  To. — To  raise  one  wing  for  the  purpose  of  turning. 

Belt. — The  haiTiess  or  strap  used  for  keeping  the  pilot 
secure  in  his  seat. 

Biplane. — An  aeroplane  fitted  with  two  pairs  of  wings  ; 
a  monoplane  has  one  pair  ;    a  triplane,  three  pairs. 

Bumps. — The  suddoi  rise  or  f;',fl  of  an  aerophine  when  it 
passes  through  disturl)ances  in  the  air  such  as  air  pockets 
or  currents.  Usually  experienced  at  comparatively  low 
heights  and  also  at  mid-day. 

Cabre.— Flying  with  the  aeroplane's  tail  slightly  down. 

Chocks.— AVooden  l)locks  placed  in  front  of  the  \\hecls 
ol  a  machine  to  prevent  it  moving  when  the  engine  is  started. 

Cockpit. — The  part  of  the  aeroplane  in  which  the  pilot 
or  observer  is  seated. 

Conk. — The  cngijie  is  said  to  "  conk  "'  wluii  it  misfires 
and  fails. 



Contact. — Word  used  to  denote  that  the  switch  is  on. 

Control  Lever.- — This  is  a  vertical  lever  in  the  centre 
of  the  pilot's  cockpit  by  means  of  which  he  controls  the  fore 
and  aft  and  lateral  movements  of  the  aeroplane.  It  is 
commonly  called  the  "  joy  stick." 

Control  Wires. — Wires  connecting  the  rudder  bar  and 
control  lever  with  their  respective  controlling  surfaces. 

Crash,  A. — ^A  flying  accident  in  which  an  aeroplane  is  so 
badly  damaged  that  it  has  to  be  deleted  or  sent  to  the  work- 
shops for  repair  and  rebuilding. 

Crash  Helmet — ^A  flying  headgear,  with  a  stiffened 
raised  cro\Mi  and  projecting  edge,  in  order  to  prevent  head 
injuries  in  the  event  of  a  crash. 

Dive. — When  the  aeroplane  descends  steeply. 

Dope. — A  varnish  used  to  render  the  fabric  of  aeroplane 
wings  impervious  to  air  and  moisture. 

Dual  Control. — ^A  double  set  of  controls,  acting  in  unison, 
fitted  in  an  aeroplane,  one  for  the  instructor  and  one  for 
the  pupil. 

Fix. — A  small  fixed  vertical  plane  fitted  in  front  of  the 
rudder  to  render  the  aeroplane  more  stable. 

FlatteninCx  Out.— This  occurs  at  the  end  of  a  glide  pre- 
paratory to  making  a  landing.  The  pilot  by  means  of  the 
control  lever  gradually  decreases  the  aeroplane's  gliding 
angle,  until  it  is  level  with  the  ground.  This  should  occur  a 
few  inches  from  the  ground.  If  the  act  of  flattening  out  is 
performed  too  late,  the  machine  hits  the  ground  forcibly, 
and  either  boimces  into  the  air  or  turns  over.  If  performed 
too  soon  the  machine  loses  flying  speed  too  high  up,  and  falls 
to  the  ground  out  of  control. 

Flying  Speed.- — The  speed  of  a  machine  through  the  air 
necessary  to  maintain  its  support. 

Forced  Landing. — ^^^^en  a  pilot  has  to  land  through 
engine  failure. 

Fuselage. — The  body  of  a  tractor  machine. 

Gadget. — A  term  applied  to  any  instrument  attached  to 
an  aeroplane. 

Glide. — To  descend  with  the  engine  cut  off  with  the 
machine  under  control  and  at  approximately  the  flying 
level  speed. 

Gliding  Angle. — The  angle  that  the  fore-and-aft  line  of 
the  machine  makes  with  the  horizon  in  order  to  make  a  correct 
gliding  descent. 

Ground  Speed. — The  speed  of  the  machine  relative  to  the 


ground,  \vhich  may  be  equal  to,  greater,  or  less  than  the  air 

Hangar.- — A  shed  for  housing  aeroplanes. 

Ham  Handed— Heavy  Handed. — A  pupil  is  said  to  be 
such  when  controlling  an  aeroplane  he  makes  rather  forced 
and  jerky  movements.  He  lacks  the  finely  co-ordinated 
movements  necessary  for  flying. 

HoiK.^ — ^This  occurs  when  a  machine  is  made  to  suddenly 
climb  steeply. 

Instrument  Board. — This  is  situated  in  front  of  the  pilot 
and  has  attached  to  it  the  compass,  spirit  level,  altimeter, 
inclinometer,  clock,  and  revolution  counter. 

Inclinometer.  —An  instrument  in  use  which  reveals  the 
angle  of  the  aeroplane  to  the  ground  hi  a  fore  and  aft  direc- 

Loop. — An  aerial  manoeuvre  in  which  the  aeroplane  is 
mt:de  to  perform  an  upward  and  backward  turn,  and  emerge 
from  it  flying  level. 

Machine." — Often  used  to  denote  the  whole  aeroplane. 

Nacelle. ^ — A  boat-shaped  body  in  some  aeroplanes, 
usually  but  not  necessarily  of  the  propeller  or  pusher  type. 

Nose.— The  front  part  of  a  machine. 

Nose  Dive.- — A  very  steep  descent  with  or  without  engine. 

Nose  Heavy.- — Backward  pressure  required  on  the  control 
level  to  make  the  machine  fly  level. 

Pancake. — The  term  applied  when  a  machine  after  losing 
flying  speed,  drops  level  to  earth  from  a  height  of  a  few  feet. 
This  occurs  through  flattening  out  too  soon. 

Pilot. — The  individual  who  works  the  aeroplane's  con- 
trols.    Pilot  aviator  is  a  better  term  or  simply  aviator. 

Propeller. — ^The  airscrew  driven  by  the  engine  which 
forces  the  machine  through  the  air.  Also  knoAvn  as  the 
"  prop,"  the  breeze  club,  or  wind  stick. 

Propeller  or  Pusher  Type. — An  aeroplane  with  the 
engijie  and  propeller  fitted  behind  the  main  planes. 

Roll. — An  aerial  manoeuvre  in  which  the  machine  is 
made  to  turn  over  sideways  in  a  circle,  and  then  continue 
flying  straight  as  before. 

Rudder. — A  vertical  controlling  surface  set  parallel  with 
the  fore  and  aft  line  of  the  aeroplane,  and  situated  at  the 
latter's  tail.  It  is  controlled  by  the  pilot  working  the  rudder 
bar,  and  its  function  is  to  steer  the  machine  to  riglit  or  left. 

Rudder  Bar. — A  cross  bar  attached  to  the  rudder  by 
control  wires,  and  controlled  by  the  pilot's  feet. 


Scout. — A  small  single-seater  machine. 

Sideslip. — A  sideways  movement  of  a  machine  through 
the  air  either  outwards  or  inwards. 

Shock  Absorbers. ^ — -Devices  for  taking  the  shock  of  the 
machine  in  landing. 

Skid. — An  inclined  portion  of  the  undercarriage  or  attach- 
ment to  the  tail  which  helps  to  take  the  shock  of  landing 
and  drags  along  the  ground  in  doing  so,  thus  slowing  up  the 

Slipstream  of  Propeller. — The  "  wash  "  set  up  in  the 
Avake  of  a  revolving  propeller. 

Soggy.  — Slow  on  the  control  and  heavy  to  handle. 

Span. — The  measurement  of  a  machine  transversely 
from  wing  tip  to  wing  tip. 

Spin,  or  Spinning  Nose  Dive. — To  go  round  ajid  round 
in  a  small  circle  with  the  nose  of  the  machine  pointing  directly 
downwards.     A  corkscrew  descent. 

Spiral. — A  steeply-banked,  continuous-gliding  tuni  (with 
engine  off). 

Stability.— The  property  of  a  machine  whereby  it  tends 
to  return  to  its  normal  flying  position  if  left  uncontrolled. 

Stall. — To  lose  flying  speed. 

Streamline. — A  shape  designed  to  offer  the  resist- 
ance to  the  passage  of  a  body  through  the  air. 

Struts. — Wooden  uprights  uniting  the  upper  and  loAvcr 

Stunts. — See  Aerobatics. 

Switch. — An  apparatus  for  cutting  off  and  on  the  electric 
current  to  the  sparking  plugs. 

Tail-Heavy. ^ — ^A  machine  requiring  the  control  lever 
always  kept  forward  a  little  in  order  to  maintain  level  flight. 

Taxying, — This  occurs  when  an  aeroplane  is  made  to 
travel  on  the  ground  by  means  of  its  own  engine. 

Throttle. — A  device  for  controlling  the  amount  of  explo- 
sive mixture  entering  an  engine. 

To  Take  a  Ticket.^ — An  aviator's  certificate  granted  by 
the  Federation  Aeronautique  Internationale. 

ToRQUE.^ — An  automatic  action  of  the  propeller  making 
the  whole  aeroplane,  while  in  flight,  tend  to  rotate  around 
its  longitudinal  axis.  This  action  is  in  the  opposite  way  to 
that  in  which  the  propeller  is  revolving. 

Tractor. — A  machine  in  which  the  propeller  is  fitted  in 
front  of  the  main  planes. 

Trailing  Edge. — The  rear  edge  of  the  wing. 


Trestle.— Wooden  frames  or  scaffolds  designed  to  sup- 
port the  tail  or  -wings  of  a  machine  when  repairs  are  l3eing 
carried  out. 

Tri PLANE.-  An  aeroplane  with  three  pairs  of  wings,  set 
one  above  the  other, 

Trueing  Up. — -Adjusting  the  rigging  of  a  machine  so  as 
to  correct  its  balance  in  the  air. 

UxDEKCAKRLVGE  OR  UxDERCHASSis. — That  part  of  a 
machine  A\hich  carries  the  weight  of  the  aeroplane  on  the 
groimd,  and  also  takes  the  shock-of  landing. 

Vertical  Bank. — A  loosely-applied  phrase  referring  to 
any  bank  over  45  degrees. 

Very's  Light. — A  coloured  light  fired  as  a  signal  from  a 
special  form  of  pistol. 

Volplane.— A  glide. 

Windscreen. — ^A  transparent  screen  mounted  in  front 
of  the  pilot  and  passenger  to  shield  them  from  the  rush  of 
air  by  the  machine  in  motion. 

WiXGs. — Tiie  planes  or  chief  surfaces  of  support. 

Zoo.^L— To  ascend  very  steeply  after  flying  level  at  full 


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Ferry  (G.). — Le  sjTidrorae  mal  des  aviateurs  (etude  experimentale  de  la 
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Fridenberg    (P.).^ — Visual   Factors  in  Equilibration,   especially   Aviation. 

Journ.   Amer.  Med.   Assoc,  1918,  Ixx.,  991. 
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1918,  Ixix.,  609-028. 
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Bull.    Acad,  de  Med.,  Par.,  1917,  3.  s.  Ixxvii.,  94-97. 
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Medical  Research  Committee. — Reports  of  the  Air  Medical  Investigation 

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ABDOMEN,  compression  of,  due  to 

safety  belt,  171 
Abdominal  conditions  of  aviators,  56 
Abdominal  injuries  from  safety  belt, 

1 5.-, 
Abdominal  muscles,  27 
Accidental  bomb  injuries,  cases  illus- 

Iratmg,  211 
Age    in  relation  to  a\iation,  20,  82 
Aerial  ambulances,  4 
Aerial  lighting,  88 

aero-neuroses  of,  109 

danger  of  collision  during,  88 

exacting  nature  of,  17 

judgment  and  resource  during,  88, 

methods  of  attack,  80 

parachute  essential  in,  175 

projectile  wounds  in,  179 

surgery  of,  204-20G 

test  for  best  type  of  aviator  for,  39 

varied  conditions  of,  70 
Aerial  frostbite.     See  Frostbite 
"  Aerochir, "  4,  5 
Apronautics,  early  handbook  on,  3 

iiiedicai  interest  in,  1 

iberapeutical  benefits  of,  3 
Aeronauts,  medical  men  as,  2,  3,  7 
Aero  neuroses,  25,  26 

bromides  in  treatment  of,  131 

cases  illustrating.  123-126 

causes  of,  96 

characteristics  and  general  obser- 
vations, 96,  97 

classification  of  cases.  118-120 

clinical   examination   in,    prior   to 
physioloc'cal  tests,  117 

common  types  of,  97 

conditions  classed  as,  96 

R  241 

Aero-neuroses — ■ 
development  of,  104 
dreams  in  cases  of,  113  , 
examination    of    the    patient,    99, 

family  history  of  cases.  1 10 

rheumatism  in,  110,  112 
following  aeroplane  accidents,  103 
frequency    of    hereditary    nervous 

instability  in  cases  of   110 
frequency  in  pilots  and  observers, 

history  of  the  ]jatient  in  cases  of, 


history  of  patient's  habits    116 
hopeless  cases  of,  132,  135 
hysterical  variety  of,  99,  101,  102 
malingerers  and,  120 
mental  type  of,  118,  120 

cases  illustrating,  123-126 

characteristics,  134 

clinical  signs  of,  120 

treatment,  129 
neurasthenic  variet}-,  99,  101 
occupational   history   of   patients, 

of  flying  pupils,  98 
of  war  flying,  109 
"oxygen  want"   cases.    119,    124 

physical  causes  of,  119,  128 
prognosis  in,  132,  135 
psychopathic  type  of  cases,    118, 

clinical  signs,  127 
rest  in  cases- of,  129 
summary  of  conclusions  on,  133 
timo  of  onset  of,  90 
toxic  type  of  cases,  118,  134 



Aero-neuroses,  toxic  type  of  cases — 
clinical  signs,  127 
clinical  signs  of,  121 
treatment  of,  105-108,  128 

summary  of  observations  on,  133 
types  of  casps  of,  100 
"  Aeropaidia  "    early    handbook    on 

aeronautics,  3 
Aero-phobia  96,  101.     See  also  Fear. 
Aeroplane   accidents,   aeroplane  de- 
fects causing,  142 
analysis  of  series 'of,  139 
arm    and    leg    injui-ies    in,    cases 

illustrating,  171-174 
brain  fatigue  causing,  145 
causes  of,  142,  181 
classification  of,  137,  174 
classification  of  injuries  due  to,  154 
construction  of  machine  in  relation 

to  severity  of,  157,  158 
engine  failure  causing,  143 
errors  of  judgment  causing,  144 
face  injuries  in,  175 
factors  relative  to,  154,  181 
fatal,  cases  illustrating,  164 
faulty  landing  causing,  frequency 

of,  149 
fear  causing,  146 
first  aid  in,  4,  149 
fractures  in.     See  Fractures, 
frequency  of,  136,  137 
general  observations  on,  136 
head  injuries  in,  155 

cases  illustrating,  164-167 
injuries  in   See  Injuries,  Fractures, 
loss  of  consciousness  causing,  147 
loss  of  head  causing,  145 
mental  condition  of  pupil  follow- 
ing, 103-104 
neurosis  following,  103 
parachute  in,  174,  175 
physical  illness  causing,  147 
prevention  of  injuries  in,  175,  176 
propeller  type,  196 
rescue  of  pilot  from  wreckage  of, 

150,  152,  182 
safety  belts  in.  159,  160 
safety  helmets  in,  162 

Aeroplane  accidents — 
shock  from,  182 
surgical  aspects  .of,  178,  181 
treatment  following,  105 
trunk  injuries  in,  cases  illustrating, 

type  in  which  jirognosis  is  adverse, 

unavoidable  causes  of,  148 
under  dual  control,  163 
variety  of  accident,  148 
Aeroplane  arrows,  injuries  from,  220 
Aeroplane  bombs.     See  Bombs. 
Aeroplane  dope  poisoning.    See  Dope 

Aeroplanes,  defective,  accident .s  due 
to,  142 
fu'st  aid  by,  4 
first  flight  by,  9 
Red  Cross  work  by,  5 
type    of    machine    in    relation    to 

severity  of  injuries,  181 
with  X-ray  equipment,  4,  5 
Aerosthenia,  96 

conditions  classed  as,  13 
Air,  temperature  of,  at  high  altitudes, 

"  Air  disease, ' '  49 
Air  Force  Medical  Service,  formation 

of,  15 
Air  pressure,  at  high  altitudes,  48,  51 
Air  raids,  precautions  during,  218 
Air  sickness,  26 

frequency  during  solo  flights,  83 
Air  stations,  first  aid  at,  149 
Alcohol,  disadvantages  of,  66 
efl'ects  of,  65,  66 

in  relation  to  physical  fitness  of 
aviators,  24 
Alkaline    treatment  of  dope  poison- 
ing, 226 
Altitudes.     See  High  altitudes. 
Ambulances,  aerial,  4 
Amputations,  in  candidates  for  avia 

tion,  22 
Ankle,  dislocation  of,  186 
fractures  of,  182 
oedema  of,  186 



Ankle — 

see  also  Astragalus. 
Ankle  joint,  limitation  of  movement 

of,  22 
Anti-aircraft  missiles,  injuries  due  to, 

Aptitude  for  flying,  19 
Arm  and  leg  movements,  co-ordina- 
tion of,  42,  43 
Arm  injuries,  cases  illustrating,  171- 

Arms,    disabilities    and    injuries    in 
candidates  for  aviation,  22 
fractures  of,  177 
frequency  of  fractures  of,  182 
Arrows,  injuries  from,  220 
Arterial  pressure.    S^e   Blood  pres- 
Artificial  limbs  in  aviitiou,  180 
Artillery  observation  pilot,  duties  of, 

89,  90 
Astragalus,  function  and  importance 

of,  187 
Astragalus  fractures,   1>ody  variety, 
cases  illustrating,  191-194 
causes  of,  184 
characteristics,  183 
complicated  variety,  186 
compression  anrl  crushing  variety, 

fliagnosis  of,  186,  187 
frequencv  of,  183 
incision  anri  exposure  in,  188 
neck  variety,  185 
jjreparation  of  skin  for  operation, 

signs  and  sj^mptoms  of,  186 
treatment  of,  187  190 
Astragalectomy,    partial,    indications 

f(H,   190 

partial  or  total,  choice  of,  188 
total,  indications  for,  190 
Athletics,  snitaMo  training  for  avia- 
tors, .■>9 
Atmospheric   pressure   nt    liigh  alti- 
tude-. 4M,  49 
Asbestos  blankets,  197 

Auditory  reaction  time,  38 
Auditory  reflex,  mechanism  of,  38 
Aural  defects  in  candidates  for  avia- 
t  ion ,  32.    See  also  Ear ;   Hear- 
Aural  pressure,  at  high  altitudes,  51 
Aviation,     accidents     during.        See 
Aeroplane  accidents ;  Crashes. 

as  a  career,  motive  for  adopting, 
71,  72 

auditory  sense  of,  44 

birth  of,  9 

candidates  for.     See   Candidates. 

causes  of  failure  in,  95 

development  of,  16,  68,  69 

first  experiences  of,  71-75 

history  of  medical  interest  in,  9-15 

imagination  in  relation  to,  82 

instruction  in,  69,  76 

literature  on   medical   aspects   of, 
1U--J3,  235 

mental  strain  during,  87,  88 

neuroses  of.     See  Aeroneuroses. 

physical  disabilities  resulting  from, 

psychology  of,  07,  93,  94 

sensations  experienced  during,  69. 
70,  74,  75 

standards  of  physical  fitness  in^  18 

surgical  work  in  connection  with, 
178,  181 

therapeutic  value  ol,  4 

See  also  Solo  flights  ;    Aerial  fight- 
ing, elc. 
Aviation  terms,  gloss jry  of,  229 
Aviators,    accidents    to.     See    Aero- 
plane accidents ;    Crashes. 

air  sickness  of,  26 

alcohol    in    relation    1o    physical 
fitness  of,  24 

arm   and   leg   movements   of,   co- 
ordination of,  42,  43 

aural  defects  in,  32 

breath  holding  test  for,  28 

causes  of  failure  of,  95 

circulatory  affections  in,  .58 

classification  of  fluties  of,  87 

diet  of,  64 



Aviators — 
duties  of,  16 

artillery  observation  pilot,  89,  90 

bombing  pilots,  91 

ferry  pilot,  92 

instriictor  pilot,  91 

reconnaissance  and  photography 
pilot,  90 

scout  pilot,  88 

seaplane  pilot,  93 

test  and  experimental  pilot,  93 
"  effector  responses  "  of,  42 
emotional  reactions  of.  39 
"  eye  "  of,  47 
first  experiences  of,  71-75 
"  flying  reflexes  "  of,  42 
"  flying  -  sense  "  of,  41,  46 
for  aerial  fighting,  grading  test  for, 

formation  of  Medical  Board  for,  13 
habits  and  mode  of  life  of,  63 
instability  of  mechillary  centres  in, 

lung  capacity  of,  how  measured,  55 
medical  men  as,  10-15 
nasal  affections  of,  32 
physical    disabilities    of.    at    high 

altitudes,  48-51 
physical  examination  of,  56 
physical  exercises  for,  59 
physical  qualifications  of,  46,  55 
physical  strain  of,  48 
psycho-motive  reactions  of,  37 
respiratory  aft'ections  of,  58 
selection  of.     See  Candidates, 
sense  of  vision  of,  45 
successful,  qualities  necessary  for, 

19,  41,  43,  46,  93,  94 
temperament  of,  19,  67,  68 

how  estimated,  97 
tol^acco    in    relation    to    physical 

fitness  of,  24 
tiaining  of,  42,  43 

factors  in,  46 
types  of,  69 

type  of  clothing  suitable  for,  62 
type  of  person  suitable  for,  19 
vestibular  mechanism  of,  44 

Aviators — 

visional  defects  of,  30,  31 

vital  capacity  of,  17,  55 

See  also  Candidates  for  aviation ; 
Pilots ;    Fiyiug  pupils. 
Aviator 's  astragalus.     See  Astragalus. 
Aviator's  sickness,  10 

BACK,   pain  in,   symptom   of   dope 

poisoning,  224 
Balance,  sense  of,  33,  34 
Balance  tests,  33,  34 
Balloon  sickness,  6 
Ballooning,  therapeutical  benefits  of, 

See  also  Aeronautics. 
Balloons,  early  ascents  in,  1 
Banking,  accidents  due  to,  144 
Barometric  pressure,  48 
Belts.     See  Safety  belts. 
Bile,  in  dope  poisoning,  225 
Bipp,  use  in  gunshot  wounds,  205,  206 
Blood  pressure,  at  high  altitudes,  8, 
10,  11,  57 

during  flying,  12 
Body,  altitude  eft'ects  on,  5,  6 

hardening  of,  59 
Body  heat,  prevention  of  loss  of,  at 

high  altitudes,  62 
Bomb  fragments,  injuries  due  to,  212 
cases  illustrating,  212 

range  of,  215 
Bomb  injuries,  12,  207,  211 

accidental,  cases  illustrating,  211 

burns,  212 

from  actual  shock  of  explosion,  211 

from  chemicals,  213 

from  fl3'ing  fragments,  212 

from  fumes,  213 
Bombing  pilot,  duties  of,  91 
Bombing  raids,  dermatitis  following, 
characteristics,  213,  214 

frost-bite  during,  198,  199 
Bomb-proof  shelters,  preparation  of, 

Bombs,  deflection  of  flight  of,  210 

destructive  effects  of,  207 
in  streets,  216 



Bombs,  destructive  effects  of — 
on  houses,  216 
on  sheds,  217 
on  shipping;  218 
dropping  of,  accuracy  in,  210 
explosive  effects  of,  210,  211 

on  sand.  217,  218 
tlight  of,  21U 

high  explosive,  207,  210,  211 
incendiarj',  characteristics,  209 
mechanism  of,  208,  209 
precautions  against,  during  raids, 

types  of,  207 
Boot,  for  astragalus  fracture.  190 
Brain  disorder,  29 
Brain  fatigue,  accidents  due  to,  145 
frequency  of,  146 
nature  of  the  condition,  145,  146 
Breakdown,    mental.     See    Aeroneu- 

Breath-holding  test,  28 
Breathing,  at  high  altitudes,  6,  53 
Breathing  exercises,  58 
Bromides,  in  Hying  neurasthenia,  131 
Bullet  injuries,  204 
Burns,  after  treatment  of,  197 
causes  and  occurrence  of,  196 
dressing  for,  197 
first  aid  measures,  154.  197 
from  i»oml)S,  212 
of  various  degrees,  197 
relief  of  pain  from,  197 

CALORIC  test,     of     vestibular     re- 
action, 36 

Candidates  for  aviation,  age  of,  20 
alcohol     in     relation    to    ])hysical 

litness  of,  24 
aural  defects  in,  32,  180 
causes  of  rejection,  21,  25 
circulatory  disorders  in,  27 
defective  vision  in,  3i» 
dental  conditions  of,  179 
<ligestive  disorders  in,  27 
disabilities  to  extremities  in,  22 
elimination  of  the  unfit,  18,  97 
emotional  reactions  of,  39 

Candidates  for  aviation — 

examination  of,  53 

family  history  in  selection  of,  20,  26 

heart  disease  and,  27 

heart  examination  in,  56 

height  of,  20 

medical  examination  of,  20,  23 

nervous  syttem  of,  29 

neuroses  and,  25,  26 

nose  and  throat  conditions  of,  179 

ophthalmic  conditions  in,  19,  180 

orthopaedic  conditions  in,  180 

physical  requirements  of,  18 

previous  health  of,  21,  25 

previous   history   of    wounds   and 
injuries  in,  21 

previous  framing  in  sports,  19,  23 

psycho-motive  reactions  of,  37 

qualities  essential  in,  19 

renal  disorders  in.  27 

respiratory  disorders  in,  28 

selection  of,  16 

special  sense  examination,  30 

surgical   measures   in   preparation 
of,  178,  179 

temperament  of,  19 

tobacco  habit  in,  24 

vestibular  reaction  of,  35 

weight  of,  20 

Sec  aUo  Flyincr  pupils. 
Carron  oil,  in  treatment  of  burns,  197 
Catarrhal  infection,  avoidance  of,  52 
Central  Air  Hospital,  formation  of,  14 
Chemicals,  in  aeroplane  bombs,  213 

skin  allections  due  to,  213 
Chest  capacity,  55 
Chest  compression  from  safety  belt, 

Chilblains,  27 

Cigarettes,  ilisadvantages  of,  65 
Circulation  at  high  altitudes,  53 

eoiidition  in  aviators,  57 
Circulatory  troubles,  at  high  altitudes, 

in  candidates  for  aviation,  27 
Clinical    examination    in    cases    of 

aeroncMrosi's,  1 17 
Clothing,  electrically  heated,  198 



Clothing — 

warmth-giving  power  of,  62 

type  suitable  for  aviators,  62 
Cold,  at  high  altitudes,  62 

exposure  to,  59,  198 

fur  as  protection  agamst,  201 

See  also  Frostbite;    Waterbite. 
Coldness  of  extremities,  27 
Colds,  avoidance  of,  52 

nature  of.  52 
Collisions,  danger  of,  in  aerial  fight- 
ing, 88 

prevention  of,  148 

with  ground,  injuries  due  to,  154 
Colour  vision,  30 

ini])ortance  of,  31 
Compression    variety    of    astragalus 

fracture,  185 
Concealed  squint,  119,  128 
Concentration,  lack  of,  21 
Concussion,  182 
Congestion  of  the  face,  122 
Consciousness,  loss  of,  during  flying, 

Crashes,  analysis  of  series  of,  139 

causes  of,  142 

definition  of,  138 

efi'ects  of  safety  belt  in,  159,  160 

fatal,  cases  illustrating,  164 

first  aid  following,  149,  150 

frequency  of,  138 

frequency  during  solo  flights,  141 

injuries    due     to.     See    Injuries; 
Astragalus ;    Fractures. 

rescue  of  pilot  from  wreckage,  150, 

under  dual  control,  163 

with  injury  to  pilot,  139 

without  injury  to  pilot,  140 

See  also  Aero])lane  accidents. 
Crushing,  injuries  due  to,  154 
Crushing  type  of  astragalus  fracture, 

Cutaneous  sensations,  45,  46 

DAY  bombing  pilot,  duties  of,  91 
Deafness,  33 
at  high  altitudes,  10 

Deafness — 

See  also  Hearing 
Death,  at  high  altitudes,  6,  7 
Defective  aeroplanes,  accidents  due 

to,  142 
Deflection  of  bomb's  flight,  210 
Dental  cleanUness,  32 
Dental  conditions,  of  candidates  for 

aviation,  179 
Dermatitis,*  chemicals    of    explosive 

bombs  causing,  213,  214 
Destructive  effects  of  high  explosive 

bombs,  216,  217 
Development  of  aviation,  16 
Diet  of  aviators,  64 
Digestive  disorders  in  candidates  for 

aviation,  27 
Direction,  sense  of,  how  tested,  36 
Disabilities  of  the  extremities,  ho\r 

estimated,  22 
Discharge  from  flying  service,  cases 

for,  132,  135 
Dislocations,  in  candidates  for  avia- 
tion, 23 
Distension,  at  high  altitudes,  50 
Dope,  application  of,  222 
characteristics,  223 
composition  of,  223 
poisonous  constituent  of,  223 
vapour  of,  223 
Dope    poisoning,    clinical    and   diag- 
nostic features  of,  225 
general  observations  on,  222 
pathology  of,  225 
prophylaxis  of,  226 
signs  and  symptoms  of,  224 
treatment  of,  226 
Dreams,  in  relation  to  aero-neuroses, 

Dressing  stations,  observations  on,  149 
Dressings,  for  burns,  197 

in  first  aid,  150 
Drowning,  from  seaplane  accidents, 

1.55,  156 
Dual  control,  accidents  under,  163 

frequenc}^  of  accidents  under,  163 
Dual  control  machines,  prevention  of 
accidents  in,  164 



Duties,  of  artillery  observation  pilots, 
of  aviators,  lli 
of  bombing  pilots,  91 
of  ferry  pilots,  92 
of  instructor  pilots,  91 
of  reconnaissance  and  photo- 
graphy pilots,  90 
of  scout  pilots,  88 
of  sea])Iane  pilots,  93 
of  test  and  experimental  pilots,  93 

EAR,    ettcct    of    high    altitudes    on, 

7,  51 
Ear  disorders,  in  aviators,  32 

in  candidates  for  aviation,  180 
Effector  movements,  42 
Electrically-heated  clothini,  198 
Elimination,  of  unfit    flying  pupils, 

K  0,  102 
Emergency  tool  kit  case,  contents  of, 


Emotional  responses,  39,  94 
Emotions,  records  of  the  influence  of, 

Engine  failure,  accidents  due  to,  143 
Epilepsy,  2 1 ,  25 

accidents  due  to,  148 
concealed  case  of,  148 
Equilibration,  sense  of,  33,  34 

how  tested,  34 
Errors  of  judgment,  accidents  due  to, 
143,  144 
examples  of,  144 
in  landing,  143,  144 
observations  on,  144 
Eusol  solution,  in  gunshot   wounds, 

2"."),  21  Mi 
Eustachian  tubes,  air  ])reBsure  on,  at 

hi^li  altitudes,  51 
Examination,  medical,  of  canrlidates 
for  aviation,  20,  23 
of  special  senses,  30 
j)hy8ical,  50 

surgical,  of  candidates  for  aviation, 
Exercises  for  aviators,  64 
Expiration,  t<st  for,  50 

Explosive  bombs,  injuries  due  to,  211 

mechanism  of,  208-211 
Extremities,  coldness  of,  27 

disal)ilities  of,  how  estimated,  22 
"  Eye,"  acquisition  of,  47 
Eye    affections,    in    candidates    for 

aviation,  180 
Eye  symptoms,  of  aeroneu  roses,  123 
Eyesight,  defective,  accidents  due  to, 

dangers  of,  30,  31 
of  candidates  for  aviation,  19,  30 
Eyes,  protection  of,  63 
by  goggleS;  163 

FACE,  flushing  of,  122 

protection  against  cold,  62 
Face  injuries,  causes  of,  175 

prevention  of,  175 
Fainting,  indications  of    liability  to, 

Faintness  during  flight,  147 

causes  of,  147 
Family  history,  in  selection  of  candi- 
dates for  aviation,  20 

in  treatment  of  aeroneuroses,  110 
Fear,  accidents  due  to,  146 

during  solo  flights,  78,  79,  81,  83, 

element  of,  101 

frequency  of,  147 

stimuli  producing,  90 

subconscious  element  of,  76 
Feet,  fractures  of,  182 

see  also  Astragalus. 

protection  against  cold,  62 
Femur,  fractures  of,  182 
Ferry  pilot,  duties  of,  92 
Fibula  and  astragalus  fracture,  186 
Fighting.     See  Aerial  fighting. 
Fighting  sense,  acquisition  of,  46 
Fighting  temperament,  42 
Fire,  escajjc  from,  in  mid  air,  196 

extinguishing  of,  in  mid  air,  196 

injuries  due  to,  155 

outl)reak  of,  196 

type  of  machine  in  relation  to,  196 

See  also  Burns. 



First  aid,  appliances  for,  150 
dressings  for,  150 
in  aeroplane  accidents,  4,  149 
Flattening  out,  accidents  due  to,  149 

errors  of  judgment  in,  144 
Flushing  of  the  face,  122 
Flying,  acquisition  of  the  art  of,  42- 
See  also  Aviation. 
Flying  accidents.     See  Aeroplane 

Flying  confidence,  leave   in  relation 

to,  12'J 
Flying  neurasthenia,  characteristics, 
clinical  signs  and  symptoms  of,  121 
summary  of  conclusions  on,  133- 

treatment  of,  130-131 
type  of  case,  118 
See  also  Aoroneiiroses. 
Flying  neurasthenics,  disposal  of,  132 
Flying  pupils,  aeroneuroses  of,  98-109 
element  of  fear  in,  101 
food  and  nourishment  before  fly- 
ing, 147 
injuries  to,  138 

instruction  following  accidents,  105 
lack    of    confidence    of,    following 

accidents,  107 
loss  of  nerve  following  accidents, 

mental    condition   following    acci- 
dents, 103,  104 
mental  condition  necessitating  dis- 
charge from  air  service,  107 
nervous  breakdowns  in,  causes  of, 

unfit,  elimination  of,  107,  108 
See  also  Instruction. 
Flying  reflexes,  co-ordination  of,  42 
Flying  schools,  instruction  at,  69 

See  also  Instruction. 
Flying  sense,  acquisition  of,  41,  46 
Flying  sickness,  50,  83,  147 
Food,  insufficient,  indirect  cause  of 
accidents,  147 
of  aviators,  64,  65 

Foot,  dislocation  of,  186 

oedema  of,  180 
Foot  movements,  42 
Formation  flying,  88 
Fractures,  177 

frequency  and  varieties  of,  182 

gunshot,  204,  205 

light  massage  in,  187,  188 

platmg  of,  182 

relief  of  pains  of,  187,  194 

mode  of  rescue  of  pilot  from 
wreckage  influencing  severity 
of,  182 

See  also  Astragalus  :    Spine. 
Frostbite,  12,  179 

at  high  altitudes,  6 

cases  illustrating,  199 

cause  and  nature  of,  181,  198 

lirevention  of,  201 

signs  and  symptoms,  198,  199 

treatment,  198-200 
Fumes,  from  bombs,  213 
Fur,     protection    against    cold    by, 

GASES,  body,  expansion  of,  at  high 

altitudes,  50,  51 
Gauntlets,  63 
Gliders,  9 

experiences  of,  9 
Gliding,  accidents  due  to,  144 
Glossary  of  aviation  terms,  229 
Gloves,  03 
Goggles,  ol)servations  on,  162 

protection  of  eyes  by,  162 

type  suitable,  63 
Gunshot  wounds,  204,  205 

antiseptic  measures  in,  205 

HABITS  of  candidates  for  aviation,      ^ 

Ham-handed,  43 

Hand  and  foot  movements,  combina- 
tion of,  42 
"  Hands,"  development  of,  87,  88 
Hands,  protection  against  cold,  63 
Head    covering,    type    suitable    for 
aviators,  63 




Head  injuries,  cases  illustrating,  165- 
causes,  155 

history  of.  in  candidates  for  avia- 
tion, 21 

Head,  loss  of,  accidents  due  to,  145 
(lefiuition  of  the  term,  145 

Headaches,  131 

symptom  of  dope  poisoning,  224 
treatment,  106 

Health,  improved  by  flying,  4 

Hearing,  defective,  33 

efiFects  of  high  altitudes  on,  7,  10 
reaction,  time  of,  how  tested,  38 
sense  of,  importance  of,  44 
test  for,  32,  33 
See  aho  Deafness. 

Heart,    condition   at  high  altitudes, 
condition  in  dope  poisoning,  226 
effect  of  aviation  on,  56 
examination  of,  27,  56 

Heart  disease,  effects  of  aviation  on, 

Heavy-footed,  43 

Height,  of  candidates  for  aviation,  20 

Helmets  for  aviators,  63 
-See  also  Safety  helmets. 

Hereditary  nervous  instability,  110 
frequency    of,    in    cases    of    aero- 
neuroses,  110 

Heterophoria,  31 

High  altitudes,  air  temperature  at,  61 
ijreathing  at,  53 
circulatory  system  at,  53 
condition  of  the  heart  at,  61 
early  researches  on  physical  effects 

of,  6-9 
effects  of,  to  what  due,  54 
effects  on  nose  and  ear,  51 
effects  on  the  l)ody,  49,  53 
frost  bite,  198.    See  also  Frostbite. 
illnes,ses  at,  6,  7,  147 
mental  activity  at,  94,  95 
oxygen  and,  47,  48 
oxygen  administration  at,  60,  61 
oxygen  content  of  air  at,  53 
physical  disabilities  at,  5,  47 

High  altitudes- 
prevention  of  loss  of  body  heat  at, 

respu-atory  difficulties  at,  28,  50 

High  altitude  test,  28 

High    explosive    bombs,    character- 
istics, 207,  210,  211 

Hopeless  cases  of  flying  neurasthenia, 
132,  135 

Hostile  air  raids,  precautions  during, 

Houses,  destructive  effect  of  bombs 
on.  216 

Hypermetropia,  concealed,  31 

Hysteria,     common    type    of    aero- 
neurosis,  97 

Hysterical    types,    of     aeroneuroses, 
101,  102 

ILLNESS,  (luring  flight,  147 

accidents  due  to,  147 

at  high  altitudes,  6,  7,  50,  83,  147 
Imagination,  in  relation  to  aviation, 

Impact  injuries,  15a 
Incendiary     bombs,     characteristics, 

Infantile  paralysis,  old  cases  of,  23 
Influenza,  and  a\aation,  4 
Injured,  aerial  trans])ort  of,  4 

how  rescued  from  wreckage,   150, 
Injuries,  accidents  without.  140 

analysis  in  series  of  crashes,    139 

causes  of,  181 

classitlcation  of,  154 

due  to  anti-aircraft  missiles,  215 

due  to  bombs.     See  Bomb  injuries. 

due  to  crushing,  1.54 

due  to  faulty  landing,  154 

due  to  impact,  l.>") 

due  to  suspension  belt,  155 

factors  determining  typo  and 
severity  of,  181 

from  aeroplane  arrows,  220 

fiom  fire,  1.55 

history  of,  in  candidates  for  avia- 
tion, 21 



Injuries — 

in  aerial  warfare,  treatment,  204- 

in  fatal  accidents,  cases  illustra- 
ting, 164 
frequency  of,  138 
from  accidents  under  dual  control, 

kind  peculiar  to  aviation,  181 
multiple,  164,  165 
parachute  in  prevention  of,  174 
prevention  of,  175,  176 
previous  history  of,  in  candidates 

for  aviation,  21 
shock  from,  182 
to  arms  and  legs,  cases  illustrating, 

to  face,  175 

to  head  and  neck,  165-167 
trunk,  cases  illustrating,  168-170 
See  also  Bomb  injuries;    Astraga- 
lus fracture ;    Fractures,  etc. 
Insomnia,  treatment,  131 
Instruction,    food    and    nourishment 
during,  147 
in  aviation,  essentials  of,  69,  70 
insufficient,  accidents  due  to,  144 
points  in,  76,  83,  86 
Instructors,  duties  and  work  of,  69, 
73,  91,  92 
pu])irs  confidence  in,  73 
qualifications  necessary  in,  92 
Intestines,    distension   at    high    alti- 
tudes, 50 
Invahding  Boards,  13,  14 
Iodine,  in  treatment  of  fractures,  189 

JAUNDICE,   symptom   of  dope 

poisoning,  224,  225 
Judgment,  errors  of.     See  Errors  of 


KNEE  jerks,  29 
Kyphosis,  production  of,  195 
t  reatment  of,  196 

LANDING,     accidents    during,    fre- 
quency of,  149 

Landing — 

and  defective  vision,  31 
errors  of  judgment  in,  143,  144 
faulty,  injuries  due  to,  154 
Lanoline,  in  prevention  of  frostbite 

and  waterbite,  201,  202 
Leave,  in  cases  of  aeroneuroses,  128, 

Leg  and  arm  movements,  co-ordina- 
tion of,  42,  43 
Legs,  injuries  to,  cases  illustrating, 
disabilities  and  injuries  in  candi- 
dates for  aviation,  22 
fractures  of,  177 
frequency  of  fractures  of,  182 
protection  against  cold,  62 
Liquid  food,  65 
Liver,  condition  in  dope  poisoning, 

225, 226 
Longevity,  ballooning  and,  4 
Loss  of  head,  accidents  due  to,  145 

definition  of  the  term,  145 
Lung  capacity,  at  high  altitudes,  55 
how  measured,  55 
See  also  Pulmonary  tuberculosis. 


attacks  during  flight,  147 

Malingering,  102,  108 
and  aeroneuroses,  120 

Massage,  in  treatment  of  fractuies, 
187, 188 

Medical  Board,  for  aviators,  forma- 
tion of,  13 

Medical    examination  of  candidates 
for  aviation,  23 

Medical  tests  of  candidates  for  avia- 
t  ion,  20 

Medullary  centres,  instability  of,  in 
aviators,  58 

Mental  activity,  at  high  altitudes,  94 

Mental    breakdown.     See    Aeroneu- 

Mental    characteristics    of    aviation 
pujnls,  82-86 

Mental    concentration,    during    solo 
flights,  85 




Mental  concentration — 

lack  of,  I'l 
Mental  distraction,  when  not  on  duty, 

Mental   fatigue,  during   solo   flights, 

Mental  inertia,  !!• 
accidents  due  to,  1-16 
brain  fatisjue  causing,  146 
Mental  strain  during  aviation,  causal 

fatiois,  M7,  88 
Mental  types,  of  acroneuroses,   118, 
li't»,  134 
cases  illustrating,  123-126 
characteristics,  134 
treat  nient,  129 
Mentality,    of    candidates    for    avia- 

t  ion,  29 
Morphine,  in  accidents,  154 
in  relief  of  pain,  187,  197 
Motive,   for  adopting  aviation  as  a 

career.  71,  72 
Motor  responses,  94 
Mouth  breathing,  condition  due  to, 

Movements,  co-ordination  of,  42 
Multiple  injuries,  164,  165 
Muscle  sense,  33 
how  tested,  34 
Muscular   movements,   co-ordination 

of,  42,  46 
Muscular  weakness,  at  hiu'h  altitudes, 

NASAL  affections  of  aviitois,  32 
of  candidates  for  aviation,  129 
Nasal  obstruction,  removal  of,  180 
Nasal  stenosis,  32 
Neck  injuries,  cases  iliustiating,  165- 

Nerve,   loss   of,   following  accidents, 

Nervous  breakdown,  in  flvint^  pupils, 

Nervous  disorders,  in  candidates  for 

aviiition,  29 
Nervous  exaltation,  at  high  altitudes, 


Nervous    instability,    causing    aero- 
neuroses,  121 

hereditary,  110 

treatment,  131 
Nervous   system,    of   candidates   for 
aviation,  29 

unstable,  indications  of,  29 
Nervousness,  during  solo  flights,  83 
Neuralgia,  and  aviation,  4 
Neurasthenia,  and  aviators,  25,  26 

characteristics,  134 

clinical  signs  and  symptoms,  121 

common  type  of  aeroneurosis,  97 

following  sj)inal  fracture,  196 

summary  of  conclusions  on,  133- 

treatment,  130,  131 

type  of  case,  IIS 

See  also  Aeroneiuosea. 
Neurasthenic  type,  of  aeroneuroses, 

101,  102 
Neurasthenics,  disposal  of,  132 
Neuroses.     See  Aeroneuroses. 
Night  blindness,  31 

test  for.  32 
Night  bombing  pilot,  duties  of,  91 
Night  flying,  ideal  conditions  for,  31 
Nightmares,  131 
Nose,  effect  of  high  altitudes  on,  51. 

See  also  Xasal. 
Nystagmus,   induction   of,   in   vesti- 
bular reaction  test,  35 

OBSERVER,  mental  strain  of,  greater 
than  that  of  the  pilot,  116 

Occupational  history,  in  cases  of  aero- 
neuroses, 112 

Oedema  of  ankle  and  foot,  186 

Ophthalmic    conditions.        See    Eye 

Oral  sepsis,  32,  117 

Orthopaedic  disabilities,  in  candidates 
tor  aviation,  22,  180 

Os  calcis.     See  Astragalus  fracture. 

Oxygen,  advantages  of,  60 

administration  during  flight,  60,  61 
air  content  of,  at  high  altitudes,  53 
and  high  altitudes,  28,  47,  48,  59 



Oxygen — 

effect  on  the  human  body,  60 
methods  of  administering,  61 
Oxygen  pressure,  dimin)shed,  49 
'•  Oxygen    want  "    cases,    of    aero- 
neuroses,  119,  124,  134 

PAIN,  of  burns,  relief  of,  154,  197 

of  fractures,  relief  of,  187,  194 
Pancaking,  143,  144 

accidents  due  to,  149 
Parachutes,  early  use  of,  3 

in  aeroplane  accidents,  174 
Paralysis,     diminution     of     oxygen, 
tension  at  high  altitudes  caus- 
ing, 54 
Passenger  fhghts,  experiences  during, 

Percussion     bombs,     characteristics, 

Petrol,  l)urns  due  to,  197 
Photography  pilot,  duties  of,  90 
Phthisis.     See    Pulmonary    tubeicu- 

Physical  disabilities,  at  high  altitudes, 
5,  47,  48 
to  what  due,  53 
lesulting  from  tiviug,  57 
Physical  examination,  56 
Physical  illness,  ace idents  due  to,  147 

during  tlisjht,  147 
Physical  requirements  of  avitators,  18 
Physical  strain  oi'  aviators,  48 
Physical  training,  58 

of  aviators,  59 
Picric  acid  dressings,  for  burns,  197 
Pilots,  accidents  with  injuries  to,  139 
accidents  without  uijuries  to.  14(^ 
classification  of,  and  their  duties, 

mental  strain  of  observers  greater 

than  that  of,  116 
rescue  from  wreckage  of  accidents, 

See  also  Instructors. 
Prognosis,  in  aeron?uroses,  132,  135 
type  of  accidents  in  which  adverse  , 

Projectiles,  anti-au-craft,  injuries  due 

to,  215 
Projectile  wounds,  179 
Projection,  sense  of,  45 

how  tested,  36 
Propeller  accidents,  181,  196 
Propeller    machines,    nature    of    in- 
juries due  to,  181 
Psychological  aspects  of  solo  flights, 

77-79.  83 
Psychology  of  aviation,  67,  93,  94 
Psycho-motive  reactions  o!  aviators, 

Psychopathic   type   of   aeroneuroses, 

118,  134 
physical  signs   and   symptoms  of, 

Pulmonary    tuberculosis,    effects    of 

aviation  on,  11 
in  candidates  for  aviation,  4,  26 
Pulse,  at  high  altitudes,  6 

condition  during  flying,  12 
Pulse  pressure,  and  aviators,  27,  28 
Pupils.     See  Flying  pupils. 
Pyorrhoea,  32 

RANGE  of  bomb  fragments,  215 
Raynaud's  disease,  27 
Reaction  times,  94 
how  tested,  37,  39 
effects  of  alcohol  on,  66. 
visual,  length  of,  144 
Reconnaissance  pilot,  duties  of,  90 
Red  Cross  work,  by  aeroplanes,  4,  5, 

151,  152 
Rejection  of  candidates  for  aviation, 

causes  of,  21,  25 
Release  of  safety  belts,  160 
Renal  system,  of  candidates  for  avia- 
tion, examination  of,  27  " 
Respiratory  difficulties,  at  high  alti- 
tudes, 48 
mechanism  and  cause  of,  50 
in  candidates  for  aviation,  26,  28 
Respiratory  rhythm,  intiuence  of  the 

emotions  on,  39 
Respiratory  system,  high  altitudes  in 
relation  to,  28 



Rest,  92 

aviator  s  necessity  of,  (54 
in  cases  of  aeroneuroses,  129 
time  necessary  for,  120 
Rheamatism,   family   history   of,    in 
cases    of    aeroneuroses,    110, 
Rotation  test,  of  vestil)ular  reaction, 

Royal  Air  Force,  formation  of,  15 

medical  service  of,  15 
Rudder,    insufficient,    accidents    due 
to.  144 

SAFETY  belt,  abdominal  injuries  due 
to,  155 
best  type  of,  160 
chest  and  abdominal  compression 

due  to, 171 
observations  on,  159 
results  of  use  in  series  of  crashes, 

use  and  release  of,  159,  160 
Safety  helmets,  how  worn,  162 
observations  on,  162 
results  of  use  of,  in  seiies  of  acci- 
dents, 162 
Sand,  explosive  effects  of  bombs  on, 

Scoliosis,  i)roduction  of,  195 
Scout  pilot,  work  and  duties  of,  88 
Seaplane  accidents,  conditions  due  to 
immersion,  179 
drowning  resulting  from,  156 
Seaplane  pilot,  duties  of,  93 
Sea-sickness,  93 
Sensations,     immediately     jneceding 

solo  flitrhts,  84 
Sense  of  balance,  33,  44 
import aiice  of,  43.  40 
Sense  of  direction,  36 
Sense  of  equilibration,  33 
Sense  of  hearing,  32 
Sense  of  projection,  36,  45 
Sense  of  vision,  30,  45 
Sepsis,  20  i,  i'(ir, 

Septic  conditions,  of  nose,  tbrout  and 
mouth,  179 

Sheds,  destructive  efi'ects  of  bombs 

on,  217 
Shell  shock,  26 
Shipping,  destructive  eflects  of  bombs 

on,  218 
Shock,  182,  194 
Sickness,  flying,  50,  83,  147 
Sight.     See  Eyesight. 
Skin,  impulses  from,  45,  46 
Skin  disorders,  198,  199 

due  to  explosive  bombs,  213 
Sleep,  necessity  for,  64 
Smoking,    and    physical    fitness    of 
aviators,  24 

disadvantages  of,  65 

eflects  of,  05 

excessive,  conditions  due  to,  24 
Solo  flights,  average  age  at   which 
undertaken,  82 

element  of  fear  during,  78,  79,  81, 

frequency  of  crashes  during,  141 

frequency'  of  sickness  during,  83 

hints  on,  76,  83,  86 

mental  concentration  during,  85 

mental  fatigue  during,  85 

pupil's  experience  during,  77,  81 

pu])irs  self'Control  during,  83-85 

sensation   immediately   preceding, 

vertigo  during,  83 
Special  sense  examination,  of  candi- 
dates for  aviation,  30 
Spinal  disorder,  29,  194 
Spinal  injuries,  168,  169 

in  candidates  for  aviation,  21 
Spine,  fracture  of,  characteristics,  194 

neurasthenia  following,  196 

telescoping  nature  of,  194,  195 
Splanchnic  flooding,  27 
Sport,  and  efficiency  of  aviators,  68 

interest  in,  in  candidates  for  avia- 
tion, 19,  23 

of  value  in  training  of  aviators,  47 
Squint,  concealed,  31,  119,  128 
Stimulants,  65,  66 

Stomach,  distension  at  high  altitudes, 



Strapping,  in  treatment  of  fractiires, 

187,  188 
Streets,  destructive  effects  of  bombs 

in,  216 
Surgical  examination   of   candidates 

fof  aviation,  20 
Suspension,  injuries  due  to,  155 
Syphilis,  25 

TACTILE  reaction  time,  38 
Tactile  reSlex,  mechanism  of,  38 
Teeth,  care  of,  32 

Telescoping  fracture  of  the  spine,  194 
Temperament  of  aviators,  41,  67,  68 
how  estimated,  97 
of  candidates  for  aviation,  19 
Temperamental  breakdown,  following 

accidents,  103 
Test  and  experimental  pilot,  duties  of, 

Tetrachlor ethane,  action  of,  224 
characteristics  and  composition  of, 

poisonous  constituent  of  dope,  223 
See  also  Dope  poisoning. 
Thermal  causes,  conditions  due  to, 
of  surgical  conditions,  178,  181 
Throat  conditions   of  candidates  for 

aviation,  179 
Tibia  and  astragalus  fracture,   182, 

184,  186 
Tin  shoe,  in  astragalus  fractures,  188, 

Tobacco.     'S'ee  Smoking. 
Tool  kit  case,  contents  of,  150 
Touch,  reaction  time  of,  how  tested, 

Toxic    causes  of  aeroneuroses,   118, 
121,  134 
clinical  signs,  127 
Tractor  machines,  injuries  from  acci- 
dents to,  158 
severity  of  injuries  received  in,  181 
Training  of  aviators,  42,  43,  46 
Trapezius  muscle,  importance  of,  in 

aviators,  22 
Treatment  at  air  stations,  149 

Treatment  at  air  stations — 

dental.  179 

first-aid,  149,  187 

of  aerial  frost  bite,  199,  200 

of  aeroneuroses,  128-135 

of  burns,  197 

of  dope  poisoning,  226 

of  fractures,  205,  206 

of  astragalus  fractures,  187-190 

of  nose  and  throat  conditions,  179 

of  skin  conditions  due  to  chemicals, 

of  spinal  fractures,  195 

of  waterbite,  202 

ophthalmic,  180 

orthopaedic,  180 
Tremor,  test  for,  29 
Trench  warfare,  aerial  wounds  com- 
pared with  those  of,  204 
Trunk  injuries,  frequency  of,  in  series 

of  accidents,  168-170 
Tuberculosis,  pulmonary.       See  Pul- 
monary tuberculosis. 
Turbinates,  180 

UNAVOIDABLE  causes,  of  aeroplane 

accidents,  148 
Unfit  candidates,  elimination  of,  97, 

102     . 
Urine,  condition  in  dope  poisoning, 


VARNISH  poisoning.     See  Dope 

Vasehne,  in  prevention  of  fiostbite, 

Vaso-motor  motability  in  aviators,  27 
Vertigo,  21 

during  solo  flights,  83 
Vestibular  mechanism,  36 

importance  of,  44 
Vestibular  reactions,  33,  34 

caloric  test  of,  36 

how  tested,  35 
Vision,     See  Eyesight. 
Visual  reflex,  importance  of,  44 

how  tested,  37 

length  of,  144 



Vomiting.     See  Sickness. 

WAR  Uying.     See.  Aerial  fighting. 
Warmth,  clothing  in  relation  to,  62 

preseivation  of,  at  high  altitudes 
Water  bite,  181 

case  illustrating,  202 

cause  and  characteristics  of,  202 

signs  and  symptoms,  202 

treatment  of,  202 

(iUust).  205 
Weight  of   candidates  for  aviation. 

Wounds,  aerial,  compared  with  1  hose 
of  trench  warfare,  204 
due  to  aerial  warfare,  treatment, 

204,  206 
history  of,  in  candidates  for  avia- 
tion, 21 
See  also  Bomb  injuries;   Injuries; 
Wounded,  aerial  transport  of,  4 
Wreckage,  rescue  of  pilot  trom.  160, 

X-RAY  apparatus,  aeroplanes  equip- 
ped with,  o